
Class & 

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COPYRIGHT DEPOSIT; 



BLOOD-PRESSURE 



IN 



MEDICINE AND SURGERY 



GUIDE FOR STUDENTS AND PRACTITIONERS 



BY 

EDWARD H. GOODMAN, M.D. 

CIATE IN MEDICINE IN ThI UNIVERSITY OF PENNSYLVANIA 



I LLUSTRATED 




LEA & FEBIGEK 

PHILADELPHIA AND NEW YORK 
1914 






Entered according to the Act of Congress, in the year 1914, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 



MAYT3J9IA 



©CI.A374232 



TO 

MY WIFE 



PREFACE 



In the opinion of so eminent a physiologist as Ludwig, 
the discovery of blood-pressure by Stephen Hales was more 
important than that of the circulation of the blood by 
Harvey. As far as its clinical application was concerned, 
the study of blood-pressure languished for many years, 
owing to the difficulty which attended its estimation in 
man. With the description by Riva-Rocci, in 1899, of an 
instrument which, by its very simplicity, immediately won 
universal recognition, the importance of sphygmomanometry 
began to be appreciated. 

The clinical study of blood-pressure is but a decade old, 
but in these few years it has furnished a great amount of 
diagnostic, prognostic, and therapeutic information. Some 
there are who still cling to the belief that the finger is just 
as trustworthy in estimating the arterial pressure as is the 
sphygmomanometer, but to those who have given the 
subject more careful consideration this contention seems 
extravagant. The sense of touch is, in some, more highly 
developed than in others; yet the man who seriously states 
that he is able to measure bodily temperature by palpation 
alone, is no more in error than is he who presumes to gauge 
the blood-pressure by means of the finger. An argument 
for the truth of this statement may be afforded to anyone 
who will palpate the radial artery and " guess," for it is 
only a conjecture, the degree of blood-pressure before using 



Vl PREFACE 

the sphygmomanometer. The marked discrepancies between 
the results furnished by the two procedures, even after 
many years in practice, will be proof enough of the value 
of the instrument. The sphygmomanometer is now as much 
a part of the physician's proper armamentarium as are the 
clinical thermometer and the stethoscope, and the assistance 
which may be expected from its routine employment should 
also be as familiar to him. 

It has been the author's aim to make fully available the 
assistance which the study of blood-pressure affords in the 
diagnosis, prognosis, and treatment of disease. The essen- 
tials are covered, and if after mastering them the reader 
is so disposed, he may range at will in an almost inexhaus- 
tible literature. E. H. G. 

Philadelphia, 1914. 



CONTENTS. 



CHAPTER I. 
Physiology of Blood-pressure 17 

CHAPTER II. 

Venous Pressure and Capillary Pressure 30 

CHAPTER III. 

Important Instruments and Methods for Estimating 

Arterial Blood-pressure 36 

CHAPTER IV. 

Non-pathological Variations of Blood-pressure in the 

Normal Man 62 

CHAPTER V. 

Hypertension and Hypotension 79 

CHAPTER VI. 

Blood-pressure in Cardiovascular Diseases, Including Dis- 
eases of the Blood §9 

CHAPTER VII. 
Blood-pressure in Renal Conditions 107 



vin CONTENTS 



CHAPTER VIII. 



Blood-pressure in Acute and Chronic Infections Including 

Certain Intoxications 124 



CHAPTER IX. 
Blood-pressure in Nervous Disorders 151 

CHAPTER X. 

Blood-pressure in Obstetrics 165 

CHAPTER XL 

Blood-pressure in Surgery 170 

CHAPTER XII. 

Blood-pressure in Certain Conditions of the Gastro- 
intestinal Tract .181 

CHAPTER XIII. 

Blood-pressure in Diseases of the Internal Secretory 

Glands 184 

CHAPTER XIV. 

Blood-pressure in Ophthalmology 187 

CHAPTER XV. 

Effect of Drugs and other Therapeutic Measures on 

Blood-pressure 190 

CHAPTER XVI. 

Treatment of Hypertension and Hypotension ... 212 



BLOOD-PRESSURE. 



CHAPTER I. 

PHYSIOLOGY OF BLOOD-PRESSURE. 

It is essential, in studying blood-pressure, that one should 
be informed concerning its physiology, for without knowl- 
edge of the physiological mechanism which plays such an 
important role, an intelligent comprehension of the sphyg- 
momanometer is impossible. The human blood-pressure 
system comprises essentially, (1) the heart; (2) the blood- 
vessels; and (3) the vasomotor regulating mechanism. The 
three are so intimately associated that disturbance of any 
one is followed by a derangement of the balance existing 
among the three. 

I. MAINTENANCE OF BLOOD-PRESSURE. 

Heart and Bloodvessels. — As far as the heart and blood- 
vessels are concerned, blood-pressure depends essentially on 
three factors: (a) the energy of the heart; (b) the peripheral 
resistance, and (c) the volume of the blood. The first two 
are of great importance, while the last has but a theoretical 
interest. 

II. BLOOD-FLOW IN ARTERIES. 

The vascular tree consists of a finely divided system of 
elastic tubes, the blood flowing through the arteries, through 
the capillaries, to the veins, the pressure being highest in 
2 



18 PHYSIOLOGY OF BLOOD-PRESSURE 

the arteries and lowest in the veins. This is designed 
for the movement of the column of blood, as a fluid must 
flow from the point of highest pressure to the point of lowest 
pressure. It is through the* activity of the heart that the 
difference in pressure is maintained. When, for any reason, 
the heart ceases to functionate, the circulation continues, 
that is, the blood flows, despite the failure of the heart, from 
artery to vein, until the pressure in these two branches of 
the vascular system has become equalized, at which moment 
the blood stream comes to a standstill. 

Despite the periodic activity of the heart, the blood is 
sent through the vessels in a continuous current, the reasons 
being, (1) the resistance offered by the arterioles and 
capillaries, and (2) the elasticity of the arterial wall. These 
two physicial properties of the vessels prevent stagnation 
of the blood during diastole, and account for its propulsion 
during this phase of the cardiac cycle. The elastic property 
of the arteries is especially concerned, for the vessel being- 
put on the stretch during systole, stores up this energy 
to discharge it during diastole, thereby contracting the 
artery and expelling the blood. One might almost speak of 
this as an echo of the cardiac systole arising in the arteries. 

Langendorff's modification of Weber's scheme of the 
circulation, conveys a good idea of the general physical 
features of the latter. 

H is a rubber bag corresponding to the heart, V and V" 
represent the inlet and outlet valves of the heart. The 
rubber tubing A is the arterial and V the venous system, 
each being provided with a pressure gauge, M" and M' 
respectively. C is a sponge in a glass tube which represents 
the resistance offered by the capillaries, the whole apparatus 
being filled with water. If one presses rhythmically on the 
bulb H, the valves V and V" act as in vivo, the column of 
water rises in M " and sinks in M f , while the tube A becomes 
more tense and the tube V more relaxed. As a result of 
the cardiac activity ( H) the pressure in the arteries is higher 
than in the veins, owing to the resistance in C. In the 
diastolic pause (release of pressure on the bulb) the pressure 
in A falls, and that in V rises, and the water is sent forward 



BLOOD-FLOW IN CAPILLARIES AND VEINS 



19 



despite the cessation of the activity of H. If particles 
are suspended in the water, the movement of the fluid 
can be plainly seen. 

Fig. 1 



W 




Weber's scheme of the circulation. 

When compression on H is discontinued, the circulation 
persists until the column of fluid in M" stands at the same 
level as that in M' '. This experiment serves to confirm 
the statement that the principal driving force for the arterial 
circulation is to be found in the heart and elasticity of the 
vessel walls. In addition to this force may be mentioned 
the contractile power of the arteries inherent in the smooth 
muscle fibers of the media. 



III. BLOOD-FLOW IN CAPILLARIES AND VEINS. 



By the time the blood arrives at the smaller arteries, 
little is to be seen of the rhythmic activity of the heart, 
that is, pulsation is generally no longer appreciated, and 
when the capillaries are reached, there is no pulsation at 
all (excepting in pathological states), although they do pos- 
sess the power of contraction. By the time the blood gets 
to the veins, the force of the cardiac systole is nil, and 



20 PHYSIOLOGY OF BLOOD-PRESSURE 

for the propulsion through this part of the vascular tree, 
the negative pressure in the thorax and the aspiration of 
blood by the diastole of the heart are called into play. 

Newer researches have demonstrated that certain veins 
are supplied with constrictor fibers, such as the portal 
vein, which receives branches from the splanchnic nerves, 
and it has been suggested, and indeed almost proved, that 
the systemic veins have a vasomotor control. Just how 
much influence these vasomotor nerves have in the circula- 
tion of blood in the veins is uncertain. 



IV. BLOOD-PRESSURE. 

1. Resistance of Bloodvessels. — In a system of tubes, such 
as is represented by the vascular apparatus, the blood exerts 
equal pressure on all parts of the vessel wall at a given 
point, but the pressure varies proportionately with the 
amount of resistance the blood has to overcome. 

Were the circulatory apparatus a rigid, unyielding set 
of tubes, the pressure would diminish in direct proportion 
to the distance from the heart. We have said above, that 
the pressure in a system of tubes depends largely on the 
amount of resistance which the circulating fluid has to 
overcome. This resistance does not arise from contact of 
the fluid with the vessel wall, for the fluid in direct contact 
with the latter is at rest, and therefore the friction must 
take place within the blood itself, the degree depending 
on the viscosity of the fluid. The amount of resistance 
which a constant uniform viscosity exerts is dependent on 
the length and diameter of the tube or vessel, and follows 
the law of Poiseuille. According to the latter: 



Q =k-n 



Q equals the amount of fluid per second issuing from 
a tube, d equals the diameter, / equals the length of tube, 
and h equals the amount of pressure necessary to drive 



BLOOD-PRESSURE 21 

blood through the vessel; k is the constant of internal 
friction. Hurthle has shown that this formula holds good 
for blood as well as for homogeneous fluids, but he claims 
the law is not applicable to a finely divided system of tubes 
like the arterial tree, on account of the elastic properties 
of the vessel wall. He prefers to regard the flow of blood, 
with decreasing blood-pressure as slower than would be 
deduced from Poiseuille's law. 1 

2. Pressure in the Various Parts of the Cardiovascular 
System. — There is but little difference in pressure in the 
larger divisions of the arterial tree, and it is not until the 
finest arterioles and capillaries are reached that a material 
decrease is observed. This decrease is still more noticeable 
in the veins and is lowest where the vense cavse empty into 
the heart. Some observers have claimed that pressure in 
the iliacs is higher than in the carotids, but Weber 2 using 
improved methods, demonstrates that this is impossible, 
and never occurs in health. 

The pressure in the veins is variable, as the following 
table of Jakobson (Langendorff) will show: 

Mm. Hg. 

V. cruralis 11.4 

V. brachialis 4.1 

V. facial, anterior 3.0 

V. jugularis 0.2 

V. anonym'a 0.1 

(From estimations made on sheep.) 

Findlay 3 has studied in the child and in the adult, the 
difference between central systolic pressure and peripheral 
pressure, using the Riva-Rocci instrument for the former 
and the Gartner tonometer for the latter. During childhood, 
the systolic pressure is uniform at different points of the 
circulation, but in adult life, the peripheral is lower than 
the central, this difference in pressure increasing with age. 
In cases of hypertension, the greater the pressure, the greater 



1 Berlin, klin. Woch., 1912, p. 773. 

2 Centralbl. f. Physiol., 1906-7. xx, p. 223. 

3 Quar. Jour. Med., 1910-11, iv, p. 489. 



22 PHYSIOLOGY OF BLOOD-PRESSURE 

the difference between central and peripheral pressures. 

Concerning the force which is necessary to rupture the 
normal artery, Grehaut and Quinquaud 1 found that the 
pressure in the carotid being equal to 150 mm. of mercury, 
7 to 11 atmospheres are required to rupture the vessel, 
or from 35 to 56 times more pressure than normally exists. 
As a general rule, it may be stated that arteries of smaller 
calibre are more resistant than arteries of larger calibre, 
the aorta, for instance, being ruptured by less pressure 
than the radial. This rule holds especially in pathological 
states. The pressure exerted on the human artery at the 
moment of rupture varies from 13 to 25 kilograms. The 
veins are but a little less resistant than the arteries. In 
pathologic states, as cerebral hemorrhage, the right carotid 
could be broken at 3.3 atmospheres and the left at 3.4 
atmospheres. The arteries near the lesion are still less 
resistant, the sylvian artery breaking at 3 atmospheres. 

3. Maintenance of Blood-pressure. — (a) Energy of the Heart. 
— This is a very important factor in the maintenance of 
blood-pressure, and plays a prominent role in its variations. 
All of the five inherent properties of the cardiac muscle 
share in this, rhythmicity, excitability, contractility, con- 
ductivity, and tonicity. Moreover, the amount of blood 
leaving the heart in a specified time has a relatively impor- 
tant share in the changes seen in blood-pressure. In gen- 
eral, it may be stated that increase in heart rate raises the 
blood-pressure, and that a lowered rate diminishes pressure. 
This is w^ell illustrated by a tracing taken from Langendorff 
showing the effect on blood-pressure of a slow heart rate 
brought about by the stimulation of the vagus. 

Note. — Experiments after cutting both vagi show that with 
the increased pulse rate there is an increase of blood-pressure. 

There are, however, many clinical observations which do 
not corroborate this otherwise very simply postulate, as 
high blood-pressure is sometimes associated with a relatively 
slow heart. This is scarcely a contradiction to the general 
statement that increase in heart rate raises blood-pressure, 

1 Journal de l'Anat. et de Physiol., 1885, xxi, p. 287. 



BLOOD-PRESSURE 



23 



since we have a corollary to it in the axiom that blood- 
pressure depends, in addition to the heart rate, upon the 
amount of blood leaving the heart in a unit of time. It 
is readily comprehensible that a slow heart by means of 
its long systole can discharge a quantity of blood sufficient 
to counteract its pressure-lowering effects. On the other 
hand, it is equally true, clinically, that a rapid heart is 
frequently associated with low blood-pressure, as on account 
of the cardiac rate, there is insufficient filling of the ventricle 
with blood, this serving to offset the blood-raising tendencies 
f the rapid heart. 

Fig. 2 



\AV N v^ 







Decrease in heart rate and fall in blood-pressure. Stimulation of vagi. 



Another purely cardiac factor in blood-pressure is the 
strength of the cardiac systole, which, when powerful, 
always raises the blood-pressure. This increased force of 
the heart systole is generally associated with increased 
resistance in the peripheral circulation, or, to express it in 
another way, the increased force of the heart is generally 
a consequence of increased resistance, and not due entirely 
to changes in the inotropic nerve mechanism. 



24 PHYSIOLOGY OF BLOOD-PRESSURE 

(b) Peripheral Resistance. — It is apparent that without 
resistance there can be no pressure, and it is equally 
apparent that the following law is applicable: the greater 
the resistance, the higher the pressure, other things being 
equal. Increased viscosity of the blood has been held to 
be one of the causes of increased resistance, and some 
observers have described a polycythemia hypertonica, the 
hypertension being due to the increase in the number of 
red blood cells. This is discussed at length in the chapter 
on heart and blood conditions, under the heading poly- 
cythemia. The internal friction of the blood may have a 
great influence in raising blood-pressure but very little evi- 
dence has been adduced as proof. The success of potassium 
iodide in cases of hypertension has been ascribed to its 
ability to diminish the viscosity, and thus lessen the high 
blood-pressure. 

Of far greater importance is the change in the size of 
the bloodvessels, whereby their lumen is increased or 
decreased, thus diminishing or increasing the resistance 
respectively. The arteries are provided with a musculature 
absolutely under the control of the nervous mechanism 
which regulates the dilatation and constriction of the vessels. 
This vasomotor tone will be considered in more detail 
on page 25, but it may be said that its normal balance 
is most important for the preservation of good health. If 
the vasomotor tone is weakened through any cause, there is 
a great fall in pressure owing to the evident general arterial 
dilatation. Great depression of blood-pressure follows, due 
to congestion of the vessels in the splanchnic field, which, 
we shall learn later, is able to accommodate all the blood 
of the body. 

Local, not extended, vascular dilatation is without effect 
on the systemic blood-pressure, although the reverse cannot 
be so positively stated. 

(c) Volume of the Blood. — This plays a subordinate role, 
in the maintenance of blood-pressure. The volume of the 
circulating fluid can be much increased, without any appre- 
ciable effect on blood-pressure, provided the increase takes 
place slowly. This is seen experimentally by the injection 



BLOOD-PRESSURE 25 

of physiological salt solution and other substances into 
animals. Failure, thus to raise blood-pressure, is due to 
three factors: (1) the rapid interchange between the vessels 
and tissues; (2) the automatical dilatation of the blood- 
vessels in order to adjust themselves to the increased amount 
of fluid, and (3) the subsequent polyuria. The last is the 
most important, the amount of urine running pari passu 
with the amount injected. 

On the other hand, losses of blood do decrease, if but 
temporarily, the blood-pressure, so that one must, in a dog, 
at least, remove about one-fifth of the total quantity of 
blood before any great depression of blood-pressure is seen. 
In man, the loss of one-half of the amount of blood causes 
death (3-3.5 per cent, of body w T eight). 

4. Vasomotor Regulating Mechanism. — (a) Vasomotor 
Nerves. — The smooth muscle of the arteries was discovered 
by Henle, and soon thereafter Stilling and Henle hinted at 
the presence of vasomotor nerves whose existence was later 
proved by Claude Bernard, in 1852. To SchifT, Ludwig, and 
Thiry we are indebted for the proof of the vasomotor 
centre. 

When a nerve which controls the vessels is cut, there 
will be a suffusion of the area supplied by the vessels under 
the control of this nerve, also an increase of the warmth 
and size of the part and of the blood pouring from the 
veins. Stimulation of the same nerve has the opposite 
effect. Depending on the extent of the vessel's nerve 
distribution, there will be a fall or rise in systemic arterial 
blood-pressure, following severing or stimulation of the 
nerve respectively. 

The vasomotor nerves are distributed in the musculature 
of the media, and since the muscle fibers are circular in 
their arrangement, the effect of stimulation is to constrict 
the lumen of the vessel (vasoconstrictor nerves). The vaso- 
dilator nerves are but little understood. Dilatation of the 
vessels has been held to be due to the influence of the longi- 
tudinal muscle fibers acting in opposition to the circular 
musculature, but Goltz believes that vascular dilatation is 
due to inhibitory nerves, which oppose the vasoconstrictor 



26 PHYSIOLOGY OF BLOOD-PRESSURE 

fibers. It is supposed by recent investigators that both 
varieties of nerve fibers are present in the same nerve trunk, 
and that depending on the quality of the irritant constric- 
tion or dilatation is effected. This view has been held by 
Pal, Strieker, and others to explain the occurrence at one 
time of vasoconstriction and at another time of vasodilata- 
tion, as for instance, in the crises of tabes dorsalis. 

(b) Vasomotor Centre. — That there is a vasomotor regulat- 
ing centre has long since been definitely proved. When the 
spinal cord in the region of the cervical portion is severed 
from the medulla, the blood-pressure falls, and when the 
same region is stimulated there will be a rise in pressure, 
both phenomena being brought about by dilatation and 
constriction respectively, of the vessels in the splanchnic 
field. The seat of this vasomotor centre is in the upper 
part of the medulla. The centre is automatic in its activity. 
It is influenced principally by three factors: (1) psychic 
states, (2) gaseous composition of the blood, and (3) reflexly, 
by cutaneous influences. 

(1) Psychic Influences. — The result of psychic influences 
is seen in pallor from fear, and in flushing, as a result of 
shame or anger, although it cannot be denied that there is 
an associated cardiac participation in these phenomena. 

(2) Gaseous Composition of the Blood. — Whenever there 
is dyspnea the blood-pressure rises through stimulation 
of the vasomotor centre, some believe, from the diminished 
amount of oxygen and others from the increased amount 
of carbon dioxid. If the breath is held, the same phenomenon 
is observed. Fig. 3 shows the effect on blood-pressure of 
artificial respiration in a curarized animal (x). 

When both vagi are cut, a curious phenomenon is observed, 
one which has been the ground for much dispute in physio- 
logical circles. Certain waves appear while the arterial 
blood-pressure is being registered (Fig. 4), consisting of undu- 
lations which show an ascending tendency (Traube-Hering 
waves). The waves are synchronous with respiration, and 
are intimately associated with the respiratory and vasomotor 
centres. Cushing 1 observed them when the vasomotor 

1 Amer. Jour. Med. Sci., 1902, exxiv, p. 392. 



BLOOD-PRESSURE 



27 



centre was evidently trying to overcome whatever was 
producing the bulbar anemia. On comparing the waves 
with the intracranial tension he was able to establish the 
fact that the crests of the waves rose above and the hollows 



Fig. 3 






L^^^^ 



. . /MV.WAY.'.w 



'■'■"'' 



,/WW" 



[ Effect on blood-pressure of artificial respiration in a curarized animal. 

fell below the intracranial pressure, and, furthermore, that 
the rise and fall of the waves was associated with blanching 
and reddening of the cortex. Cushing believes that the 
phenomenon is but an exaggeration of the normal rhythmic 
waves of blood-pressure seen under many conditions. 

Fig. 4 




Traube-Hering waves. 



Wolf and Plumier 1 regard the Traube-Hering waves as an 
expression of rhythmical vasoconstriction extending to all 
the vessels of the body, arising from a stimulus sent out 

1 Journal de Physiol, et de Path, gen., 1904, p. 213. 



28 PHYSIOLOGY OF BLOOD-PRESSURE 

from the respiratory centre to the vasomotor centre at 
each inspiration. The heart plays little part in the pro- 
duction of these waves. 

Rhythmical variations of true cardiac origin have been 
described by Cushing. 1 Knoll, 2 Winterberg, 3 and Stras- 
chesko. 4 

For a full discussion on the recognition of the various 
waves of blood-pressure, the reader is referred to an able 
article by Morawitz. 5 

(3) Reflex Influences. — Very mild irritants applied to 
the skin, such as blowing on the skin, or light contact, 
cause a rise in pressure but strong stimuli are without 
effect. Certain sensory nerves, which, when stimulated, 
give rise to increase of blood-pressure, have a depressor 
function when the stimulus is applied to narcosis. Such a 
nerve possessing these two properties has been discovered 
by Ludwig and Cyon (N. depressor). It arises from the 
vagus and the superior laryngeal nerve, and terminates 
in the heart muscle itself. It is believed that vasodilatation 
and depression of blood-pressure follow its stimulation and 
LangendorfT hints at the possible existence of a vasodilator 
centre. 

(c) Spinal and Peripheral Vasomotor Centres. — The chief 
regulating influence of the bloodvessels lies in the vaso- 
motor centre, whose duty it is to assume charge of all 
bloodvessels. The work of this centre, is, so to speak, 
apportioned out among lesser vasomotor centres, which 
regulate the activities of local vascular fields, and whose 
seat is in the thoracic portion of the spinal cord. This 
seems to be definitely proven, inasmuch as the lowered 
blood-pressure which follows division of the medulla, rises 
again, and disappears entirely when the spinal cord is 
destroyed. These spinal centres are excited by dyspneic 
and reflex stimuli but to a much less degree than the medul- 
lary centres. 

1 Journal of Phys., vol. xxv, p. 49. 

2 Sitzungsber. d. k. k. Akad. der Wissensch., Wien, 1890, Band xcix; 
Abt. 3, and 1894, Band ciii, Abt. 5. 

3 Zentralbl. f. Phys., 1906-7, vol. xx, p. 872. 

4 Arch, fur die ges. Phys., 1909, cxxviii, p. 1. 

s Arch, fur Anat. und Physiol. Phys., Abt., 1903, p. 82. 



BLOOD-PRESSURE 29 

Goltz and Ewald have shown that the arterial tone is 
reestablished even after almost complete removal of the 
spinal cord, and it is believed that in addition to the central 
and spinal centres there are peripheral centres located 
either in the sympathetic ganglia or in the vessel walls 
themselves. 

(d) Anatomical Consideration of Vasomotor Nerves. — Ac- 
cording to the newer division of the nervous system into 
the autonomous and vegetative, whereby the former com- 
prises the nerve distribution to the motor (muscle) portion 
of the anatomy, and the latter the organic portion, the 
vasomotor nerves fall in the class of autonomous nerves. 
The vasoconstrictor fibers arise in the spinal cord, and leave 
it through the anterior root, running in the white Rami 
communicantes to the gangliated cord. The cerebrospinal 
fiber as such, never reaches the organ, but becomes merged 
in the sympathetic nerve, whose termination in the organ is 
a sympathetic neurone. The following table gives the point 
of exit of nerves supplying various portions of the body : 

Head: First to fifth dorsal vertebras, especially second and third. 
Upper extremity: Fourth to ninth dorsal vertebrae. 
Lower extremity: Tenth to eleventh dorsal to third or fourth lumbar. 
Abdominal organs: Fifth dorsal to third lumbar; kidneys especially 
eleventh to thirteenth dorsal. 

Lungs: Second to seventh dorsal, especially third to fifth dorsal. 

The vessels of the head are governed by the vasomotors 
in the cervical sympathetic, and destruction of the upper 
cervical ganglia is followed by dilatation of these vessels. 
Stimulation is followed by pallor, a phenomenon often 
observed in man. Vasomotor nerve supply to the lungs 
is a matter of some dispute, Wood claiming that there are 
pulmonary vasomotor fibres. The heart muscle receives 
constrictor fibers through the vagus, while the sympathetic 
carries dilator fibers for the coronary arteries. 

All the abdominal organs receive vasoconstrictor fibers 
through the splanchnics, and it is for this reason that the 
splanchnic nerve is the most important pressure regulating 
nerve in the animal economy. 



CHAPTER II. 
VENOUS PRESSURE AND CAPILLARY PRESSURE. 

I. VENOUS PRESSURE. 

Although the study of arterial blood-pressure has 
dominated the interest of clinicians, it is perfectly com- 
prehensible that it is, after all, but one of the many factors 
of blood-pressure, and that capillary, and especially venous 
pressure, should not be wholly neglected. The reason why 
venous pressure in man has not been more generally studied, 
is because of the lack of a method applicable to general 
clinical use. Simplified methods and more detailed study 
with accurate instruments will doubtless furnish much infor- 
mation of clinical value. In this chapter an attempt will 
be made to review the more important methods devised 
for determining venous pressure. 

A method of estimating venous pressure by means of 
weights was described by Frey. 1 His idea was to compress 
the veins by the use of gradually increasing weights, in 
much the same way as one uses the fine chemical balance. 
The pressure read would equal the number of grams necessary 
to compress the vessel. 

In a later paper 2 he describes a simple instrument, con- 
sisting of a piston with a spring plunger. The end of the 
syringe-like arrangement is placed on the vein of the arm 
held on level with the right third rib, and one reads off on 
the scale in the barrel of the syringe the amount of pressure 
in grams. The pressure in health is given as 10 to 15 grams. 

Gartner 3 devised a method for estimating the pressure 



1 Deutsch. Arch, fur klin. Med., 1902, lxxiii, p. 511. 

2 Medizinische Wochen., 1904, p. 77. 
s Munch, med. Woch., 1903, p. 2038. 



VENOUS PRESSURE 31 

in the right auricle. He suggested that the veins might 
be regarded as a manometer tube whose termination is in 
the right auricle, and he believed that, when the arm is 
slowly raised, the level at which the veins on the hands 
disappear, measured above the fifth rib (site of the right 
auricle), will give the pressure. In health the veins collapse 
when the hand attains the level of the fifth rib, therefore 
venous pressure is nil. In cardiac insufficiency, the arms 
must be raised higher to cause collapse of the veins. As 
ingenious as this method is, it possesses many fundamental 
weaknesses which do not make its usefulness an assured 
fact. 

Oliver, and later Sewall 1 used a spring blood-pressure 
gauge. By this method pressure is exerted on a superficial 
vein, which is then milked toward the heart. The pressure 
is slowly released until the milked portion is seen to fill. 
At this instant the pressure is read off by noting the tension 
of a spring previously calibrated against mercury. Hooker 
and Eyster make objections on account of difficulty of 
calibration and the likelihood of mechanically raising the 
venous pressure distally. 

The first to use air pressure was von Basch. 2 He em- 
ployed for this purpose a modification of his instrument 
devised for estimating capillary pressure. The same 
principle was used by Recklinghausen 3 in an ingenious 
but complicated modification, with a transparent pneumatic 
pelotte. He found that the pressure was practically zero. 

Following their leads, Hooker and Eyster 4 introduced an 
aluminium frame, so cut as to fit the arm, and closed below 
by a thin rubber sheet with a rectangular opening, and above 
by a glass plate. The opemng in the rubber dam is placed 
over the vein, and by raising the pressure in the box, the 
vein is collapsed, the amount of pressure required to bring 
this about, being read in centimeters of water. With their 
method, the normal venous pressure averaged 8 cm. In 

1 Quoted by Hooker and Eyster. 

2 Wien. med. Presse, 1904, p. 961. 

3 Arch, fur Path, und PharmakoL, 1906, Iv, p. 468. 
* Johns Hopkins Hosp. Bull., 1908, p. 274. 



32 VENOUS PRESSURE AND CAPILLARY PRESSURE 

some cases of heart disease this was greatly raised. Accurate 
determination of blood-pressure is impossible when there 
is phlebosclerosis, a condition which Hooker and Evster 
met with quite frequently. y 

By far the best method is the one described by Moritz 
and v. Tabora.^ This is based on the principle, that if a 
communication is made between a vein and a manometer 
tube filled with water, the fluid in the latter will flow into 
the vein until the pressures in both become equivalent. 
1 he patient is placed in a horizontal position, the right arm 
is abducted to a right angle, slightly flexed at the elbow 
and the hand brought in a position of half pronation. This 
is the position least likely to cause obstruction to the flow 
01 blood m the veins. 

A bandage is tied around the upper arm, and, observing 
the usual aseptic precautions, a needle is introduced into 
the vena mediana, and some blood withdrawn in order to 
see if the ran has been entered. The needle is then con- 
nected with a tubing filled with an antispetic solution 
(1 gram chmosol m 2000 c.c. sterile Ringer's solution) and 
the fluid allowed to flow into the vein until it stops, at which 
point the venous pressure is read off, this being the point 
where the pressure in the veins and the pressure in the 
manometer are equalized. 

This method is undoubtedly very exact and occupies 
no more time than does an ordinary intravenous injection 
and in the hands of Moritz and v. Tabora no unpleasant 
complications have arisen. The normal pressure corresponds 
to 40 to 80 mm. water, and the upper limit of normal they 
place at 80 to 100 mm. water. In pneumonia with decom- 
pensation the highest value was found, namely, 320 mm 
water When fully compensated, heart diseases show 
normal blood-pressure, but with signs of decompensation 
a rise is seen. In health, exertion causes a decided rise 
which is even more pronounced in decompensating cardiac 
lesions. The only valid criticism which one can make to 
this method is, that it is applicable only in the clinic, and 
its use is absolutely precluded in the consulting room, 

1 Deutsch. Arch, fur klin. Med., 1909-10, xcviii, p. 475, 



CAPILLARY PRESSURE 33 

The latest writer on the subject is A. A. Howell 1 who 
seems to have devised a fairly accurate method for the 
estimation of venous pressure under circumstances which 
do not permit of the use of the Moritz-v. Tabora technique. 

Ho weirs normal figures of 7.6 cm. of water compare 
favorably with those of Moritz and v. Tabora (40 to 80 mm.). 
In circulatory diseases with more or less decompensation, 
there was an elevation of venous pressure. 

At present there exist very scanty references to the 
condition of venous pressure in disease. Judging from the 
prominent position the venous system occupies in sphygmo- 
graphic work, it is not too much to suppose that a study of 
venous pressure will prove a valuable complement to arterial 
pressure. The nerve supply of the veins make it not at all 
improbable that the venous pressure undergoes considerable 
variation in pathological states, for it has been suggested 
that shock is probably a manifestation of depression of the 
venous pressure mechanism. 

Drugs have some action on the latter, as a fall in venous 
pressure has been noted after nitrites and morphin. 

Schott 2 has made some interesting studies with the 
Moritz-v. Tabora method, in observing the effect of exercise 
on venous pressure in various pathological states. His con- 
clusions are, that persons with healthy hearts show no or 
but very little rise in venous pressure after exercise. It is 
possible, then, that in a study of venous pressure we may 
have a valuable means of estimating the functional capacity 
of the heart. 

H. CAPILLARY PRESSURE. 

The first studies in capillary pressure were by Roy and 
Brown on the frog, using a method whereby the pressure, 
necessary to make a part bloodless, is recorded. In man, 
v. Kries (1875) reported the first observations, using a 
glass plate which he pressed on the back of the finger until 



1 Arch. Int. Med., 1912, ix, p. 149. 

2 Deutsch. Archiv fur klin. Med., 1902, cviii, p. 537. 



34 VENOUS PRESSURE AND CAPILLARY PRESSURE 

the underlying skin became pale, and then calculated the 
hydrostatic pressure from the weight required to blanch an 
area of the skin. 

v. Basch 1 has made a modification of v. Kries' method, 
measuring the capillary pressure directly, with a manometer. 



Fig. 5 




v. Basche method of estimating capillary pressure. 

The glass funnel, A, whose larger end is closed with a 
cemented cover glass, is placed on the dorsum of the finger, 
immediately behind the nail, putting a little mucilage 
around the skin so as to make the funnel air-tight. From 
A, a side arm leads to a T-tuhe connecting with a manometer 
and a rubber bulb. When the skin becomes blanched, the 
amount of pressure is read off. The normal pressure thus 
registered corresponds to 25 to 30 mm. Hg, but the arterial 
pressure and capillary pressure do not run pari passu. 



Wien. klin. Rundschau, 1900, xiv, p. 549. 



CAPILLARY PRESSURE 35 

The capillary circulation is slowest in the morning and 
most rapid in the evening, and this phenomenon has been 
held to explain the fact that the arterial blood-pressure is 
highest in the morning and lowest in the evening. 

Lombard 1 studied the capillary pressure by a modification 
of v. Kries' method, and by a modification of Roy and 
Brown's technique. He states, that, when a gradual in- 
creasing pressure is exerted on the skin on the back of the 
hand, the superficial vessels are emptied in the following 
order: the subpapillary venous plexus, superficial venous 
branches, the venous arm of a part of the capillary loop 
(these have the lowest pressure), the arterial arm of the 
same loop, and the venous, and later the arterial com- 
ponents of the remaining capillary loops (the pressure 
varying in these). 

He has estimated the pressures to be the following when 
the hand is held about 10 cm. below the second intercostal 
space. 

Mg. Hg. 
Subpapillary venous plexus . . . . . . . . 10 to 15 

Most superficial venous branches 15 to 20 

Easiest compressed capillaries 18 to 22 

Medium-sized capillaries 35 to 40 

Most resistant capillaries and branches of the arterioles 60 to 70 

These figures, he states, were obtained in normal indi- 
viduals of various ages and at ordinary room temperature. 

From a clinical stand-point the study of capillary pressure 
promises very little, at all events, the information so far 
obtained seems to be without much import. 

1 Zentralbl. fur Phys., 1911, xxv, p. 157. 



CHAPTER III. 

INSTRUMENTS AND METHODS FOR ESTIMATING 
ARTERIAL BLOOD-PRESSURE. 

I. BRIEF HISTORICAL SKETCH. 

Since Harvey propounded his theory of the circulation 
of the blood, physiologists have occupied themselves with 
the question of estimating the degree of blood-pressure, its 
variations, and its relation to pathological and physiological 
phenomena. As early as 1733 Stephen Hales published 
an account of experiments made in this direction. In his 
Statical Essays 1 he says, "Several ingenious persons have 
from time to time attempted to make estimates of the 
force of the blood in the heart and arteries, who have as 
widely differed from each other as they have from the 
truth, for want of a sufficient number of data to argue 
from," and he adds that if they had taken their data from 
a regular series of experiments they would have been able 
to get nearer the truth. "Finding but little satisfaction 
in what had been attempted on this subject by Borellus 
and others, I endeavored about twenty-five years since to 
find what was the real force of the blood in the crural arteries 
of dogs, and about six weeks afterwards I repeated the like 
experiments on two horses and a fallow doe." He was the 
first to use the "Hydraulick Way" in making these experi- 
ments. The instrument devised by Hales was a cumber- 
some affair. It consisted of a brass pipe one-sixth of an 
inch in diameter which he inserted into the crural artery 
of the animal (a mare) to which was attached "by means 

1 Statical Essays; containing Hasmastaticks; or an Account of Some 
Hydrostatical Experiments Made on the Bloodvessels of Animals, London, 
1733. 



BRIEF HISTORICAL SKETCH 



37 



of another pipe whieli was fitly adapted to it" a glass tube 
nine feet in length and of about the same diameter as the 
other tube. The blood from the artery gradually rose into 
the tube to about eight feet, rushing up about half way at 
once and then ascending from twelve inches to one inch 
at each pulsation. 

In 1829, Poiseuille replaced this long tube by a U-shaped 
one about 7 mm. in diameter containing mercury; the 
smaller arm of the U was bent at right angles and its free 
end was supplied with a stopcock. After being filled with 
bicarbonate of soda as a coagulant, it was inserted into the 
artery. The force of the blood-pressure was estimated by 
the change in the level produced in the mercury in the two 
tubes. Poiseuille called his instrument a hsemodynameter. 



Fig. 



[ 




Apparatus of Guettet. 

In order to facilitate the measurement, it became de- 
sirable that the movement of the mercury be limited to 
one tube only, and Guettet now constructed an apparatus 1 
(Fig. 6) in which the mercury was contained in a flask into 
the top of which the tube, bent at right angles, destined to 
be inserted into the artery of the animal under experimenta- 



1 Morat et Doyon, Traite de Physiologie, vol. i, p. 133. 



38 



ESTIMATING ARTERIAL BLOOD-PRESSURE 



tion, was inserted, while another tube was fitted vertically 
to the lower side of the flask. The displacement of the 
mercury thus took place only in the vertical tube. The 
force of the pressure was estimated less the weight of the 
anti-coagulant used. The errors in value derived from this 
instrument, due to the large size of the tube, the oscillations 
of the mercury in the upright tube, etc., were overcome in 
the modification devised by Magendie (Fig. 7) which ren- 



Fig. 7 





Magendie's modification. 



dered the latter's model as superior to Poiseuille's as Poi- 
seuille's was to that of Hales. In this apparatus the tubes 
were only about 2 mm. in diameter. While these instruments 
indicated, they failed to record the variations in blood- 
pressure, and, moreover, they required the assistance of 
several persons for their manipulation. 

With the introduction of Lud wig's kymographion, in 1847, 
we have the first instrument in which the results of the 
blood-pressure measurements are recorded graphically (Fig. 



BRIEF HISTORICAL SKETCH 



39 



8). 1 An ivory floater with a long light handle is introduced 
into a U-shaped tube. The smaller arm of the U is bent 
at right angles and is fitted with a rubber tube for insertion 
into the artery, and with a robinet for regulating the flow 
therefrom. The oscillations in the mercury are accompanied 
by oscillation of the floater, which makes its records on a 
paper-covered revolving cylinder. The tracings show the 
different waves, the smaller ones representing the systolic 



Fig. 




Ludwig's kymographion. 

beats, and the larger ones being due to respiratory move- 
ments. A serious defect of this instrument was the want 
of continuity in the contact of the recording pencil with the 
cylinder. Volkmann, endeavored to remedy this by support- 
ing the pencil with a thread. The instrument was sub- 
sequently modified by others, but the changes introduced 
were unimportant. The modification made by Roy, much 

1 Marey, La Circulation du Sang, 1881, p. 177. 



40 ESTIMATING ARTERIAL BLOOD-PRESSURE 

used in laboratory work in France, 1 consists of a manometric 
U-tube, the smaller branch of which is supplied with rubber 
tubing the free end communicating with the artery. A 
stop-cock on the tube regulates this communication. The 
floater is maintained in a vertical position by a metal ring 
at the top of the longer arm of the U. 

Ludwig's instrument did not give the total arterial blood- 
pressure, the mercury rising to the same level in both 
branches of the tube; total pressure was obtained by doubling 
the highest figure. None of these instruments so far devised 
registered mean blood-pressure, for it is well known that 
the pressure varies constantly in the blood vessels. Setsche- 
now, and later, Marey, added value to the kymographion 
by an improvement by which this figure could be obtained. 
On the manometer of Ludwig's machine Setschenow placed 
a robinet at the bend of the glass tube. Closing this cock 
caused a gradually diminishing illumination in this part of 
the tube. The decreasing oscillations were thus easily 
seen and the level of the mercury in the larger branch 
remained stationary, varying only with the total blood- 
pressure. Making use of this principle, Marey constructed 
a compensating manometer which acts as a control to the 
graphic record of the kymographion. To a Guettet mano- 
meter flask (the one employed by Magendie and frequently 
known as Magendie cardiometer) he attached two tubes, 
one narrowed at its base to prevent too rapid movements 
in the mercury, and next to this he placed an oscillating 
column which communicates with the same reservoir. 
The column remained stationary between the maximum 
and minimum, giving the mean pressure. Another improve- 
ment was added by Chauveau, in which the floater is 
regulated by means of a thread passing over pulleys. At 
a certain point a fine pencil is affixed to the thread, and this 
recording point follows the movement of the thread and 
thus of the mercury 2 (Fig. 9). 

Many of the defects of the apparatus devised since 
Poiseuille, were by this time remedied, but there still per- 

i Vaschide et Lahy, loc. cit., p. 357. 2 Ibid., p. 356. 



BRIEF HISTORICAL SKETCH 



41 



sisted the inconvenience due to the inertia of the mercury. 
Milne-Murray next constructed a large instrument in which 
the U-tube was partially filled with water. A piston, which 
follows the movements in the water as they are transmitted 
by the arterial pressure, is held by a fine wire passing over 
pulleys, and the recording point attached records the 
slightest motion in the water. The weight of the recording 



Fig. 9 




Marey-Chauveau compensating manometer. 



point is sufficient to hold the thread in place. In 1878, 
Francois Franck introduced a number of important modi- 
fications into Ludwig's original apparatus and with these 
and some subsequent changes he may be said to have given 
the instrument its attainable perfection. These modi- 
fications related principally to the constant zero, which 
,was obtained by the mobility of the graduated scale, and 



42 



ESTIMATING ARTERIAL BLOOD-PRESSURE 



to the wire thread which guides the floater, which he replaced 
by a hair attached at two places on one of the tubes; the 



Fig. 10 



■\ r 




a r 




Instrument of Hiirthle. 



management of the whole apparatus was also much facili- 
tated by being mounted on a revolving base, and the mano- 






BRIEF HISTORICAL SKETCH 43 

metric tubes were also improved. Franck also devised a 
double manometer for recording arterial pressure simultane- 
ously at two different points, or arterial and venous pressure 
at the same time. 

An entirely and original instrument was at this time 
constructed by Hurthle — whose researches in this field 
are numerous and important — a maximum-minimum mano- 
meter, which, as its name indicates, registers maximum 
and minimum pressures. The curves of variations, how- 
ever, are not recorded, and these figures must be deduced 
from the figures obtained 1 (Fig. 10). 

As has already been stated the inertia of the mercury 
was a constant serious source of error in the apparatus 
hitherto employed, and investigators now turned their 
attention to the feasibility of metal manometers. Fick, 
in 1878, w T as one of the first to make the attempt, but in 
his endeavor to overcome the faults of the mercury he 
encountered a new obstacle in the instability of metallic 
transmission. But this source of error has been gradually 
eliminated and some very sensitive metal manometers, 
have been produced. The apparatus devised by Fick, 
(Federmanometer) is well known in all physiological labor- 
atories. In this the blood-pressure acts on a tube connected 
with a spring (from which the instrument derives its name), 
which in turn communicates with a fine recording point. 
The instrument as first reported in a special publication 2 
was afterward improved and Fick, 3 describes it as "a 
direct recording manometer in which, with the exception 
of the very light weight recording point, no inertia of any 
kind plays an appreciable role." 

Marey's name stands forth in this connection as a meth- 
odical and original worker in this field of research. In fact, 
he paved the way for modern investigators, and, as will 
presently appear, many of the instruments widely in use at 
the present day are based on the principle laid down by him. 

1 Vaschide et Lahy, loc. cit., p. 359. 

2 Festschrift zur dritten Saecular Feier der med. Fac. zu Wiirzburg, 
Leipzig, 1882. 

3 Archiv fur die gesamte Phys., 1883, xxx, p. 597. 



44 ESTIMATING ARTERIAL BLOOD-PRESSURE 

In his instrument which is virtually a sphygmoscope, the 
blood-pressure acting on a metal capsule (of an aneroid 
barometer) filled with water and enclosed in a flat-bottomed 
vase, causes a change in the level of the alkaline solution 
in the upright tubes, which form part of the apparatus, and 
the changes are recorded by a fine point. The instrument 
is one in which a metallic membrane replaces a rubber one. 

The inaccuracy of the mercurial manometer also led 
him to devise a simple and ingenious way of overcoming 
this fault, viz., the use of an elastic body for transmitting 
the blood waves to a metal recording manometer. This 
consists of a wide, short, glass tube, fitted with a cork at 
one end through which an ordinary piece of glass tubing 
extends into the wide tube; an elastic pouch, likewise 
pierced by a piece of glass tubing and covered with a 
rubber finger is introduced into the lower end of the wide 
glass. After being filled with an alkaline solution, and the 
air having been expelled from the rubber finger, its tube 
is inserted into the artery. The tubing at the other end of 
the wide glass communicates with a metal manometer. As 
the blood-pressure in the interior of the ampoule increases 
it inflates the rubber and displaces some of the air in the 
glass which envelops it. The variations are recorded by 
the fine recording point (Fig. 11). 

Very important contributions to the technique of blood- 
pressure estimation have been made by Hiirthle. Besides 
his numerous experiments and comparative studies with his 
apparatus and those of his predecessors, he has described 
various appliances which with more or less modifications 
are much used in German and English laboratories. These 
apparata are variously known as the spring manometer, 
the rubber manometer and the maximum-minimum mano- 
meter, already alluded to. Their names indicate the salient 
features of their mechanism. 

The force of arterial pressure has been employed to unroll 
a torsion thread, the motion acting on a recording pencil. On 
this principle Roy constructed his torsion manometer. The 
blood enters the tube at the base of the instrument. An 
ebony piston held by a torsion thread closes the upper por- 



BRIEF HISTORICAL SKETCH 



45 



tion of the tube. The torsion thread is attached to a long 
straight piece of steel, the length of the latter affecting 
the sensitiveness of the instrument. A recording point is 
attached to this steel rod, and when the experiment is com- 
pleted the results are measured by comparison. 



Fig. 11 



{=\ 



Marey's sphygmoscope. 

It will be readily seen that the technique for these instru- 
ments — the direct introduction of a tube into the artery — 
is applicable only to animal experimentation, or to man, 
when by chance a bloodvessel is exposed during ampu- 
tation of a limb. Faire, 1856, was the first to use the 
method in man when he inserted a Magendie's manometer 
in arteries exposed during operation, but it is to Marey to 
whom we owe the first clinical instrument for determining- 
arterial blood-pressure, but this was not perfected until 1878. l 

In 1855 Vierordt conceived the idea of estimating the 
force of arterial blood-pressure indirectly by estimating 
the amount of counter-pressure required to obliterate an 
artery. After Marey had added the sphygmoscope to his 
spring apparatus, several physiologists endeavored to 
make use of the device for measuring the force of arterial 
pressure. Forster, 1867, and Behier, 1868, attempted to 



Shaw, Medical News, 1901, Part I, p. 373. 



46 



ESTIMATING ARTERIAL BLOOD-PRESSURE 



determine the force expressed on an artery by the spring, 
by means of a needle running over a dial plate set in motion 
by a regulating screw. At each turn of the screw the needle 
advanced a certain number of points. But the construction 
of this instrument was faulty and the results unreliable. 
Landois simply added weights to the spring of the syphygmo- 
graph until the artery was obliterated and he claims to 
have found that in students in good health it required 550 
grams to occlude the radial artery, the artery being weighted 
for a length of 4.1 c.mm. Philadelphien's sphygmograph 
is another apparatus of this period in which by means of 

Fig. 12 ' 




Philadelphien's sphygmograph. 

weights, changeable at will, the pulse waves are registered 
with different known weights, the process being carried out 
until the pulse disappears. The weights correspond to the 
arterial pressure 1 (Fig. 12). 

The manometers thus far described, recorded constant 
pressure but they failed to note variations in blood-pressure. 
Marey's simple and ingenious sphygmograph, it is true, 
indicated these modifications, but this in turn gave no 
information as to their extent. He himself observes 2 "the 

1 Vaschide et Lahy, loc. cit., p. 359. 

2 Circulation, p. 220, quoted by Potain, Arch, de Physiol., 1889, i, p. 559 



INSTRUMENTS 



47 



sphy gmograph gives us no absolute values for the blood- 
pressure in the arteries, it merely expresses a relative value." 
Marey, and later Mosso and his followers, measured the 
force of arterial blood-pressure by obliterating all the blood- 
vessels leading to an artery. 

H. MODERN INSTRUMENTS FOR CLINICAL USE. 

It will be unnecessary to describe in detail, all the instru- 
ments which have been devised for measuring the arterial 
pressure, as a great many are now obsolete and possess 
only an historical interest. 

v. Basclis sphygmomanometer, inasmuch as it was the first 
to use but a single artery for compression, may be regarded 
as the pioneer. This instrument was first described in 
1882 1 and with it the hitherto uncertain estimation of the 
force of variation and amount of blood-pressure gave way 
to concrete figures. (Fig. 13.) 

Fig. 13 




v. Basch's sphygmomanometer. 



v. Basch based his invention on the hydrostatic appa- 
ratus employed in animal experimentation. He eliminated 
springs or weighted pads as a means of compression, inas- 



200. 



Wien. med. Woch., 1883, p. 083; Berlin, klin. Woch., 1887, pp. 179 and 



48 ESTIMATING ARTERIAL BLOOD-PRESSURE 

much as the pressure in his instrument is exercised by 
means of a rubber capsule filled with water, which he terms 
a "fluid pelotte." This pelotte is pressed against the artery 
and the fluid expands according to the force of arterial pres- 
sure. The degree of expansion is recorded on a manometer 
connected by a rubber tube with the pelotte into which the 
fluid runs. In his original apparatus a mercury manometer 
was used, but v. Basch afterward replaced this by a metal 
one constructed on the principal of an aneroid barometer. 
Potain modified this by using air under slight pressure 
instead of water on the pelotte. Potain's instrument, which 
is much used in France, resembles v. Basch's in nearly 
every particular except this, but the skill required for its 
manipulation and the subjective relations of the operator, 
are defective features of the instrument. 1 

The Rim-Rocci instrument is the parent of all our modern 
sphygmomanometers, practically all the mercury instruments 
being developed from Riva-Rocci's original design. This 
was described at a meeting of the Italian Congress for 
Internal Medicine in 1896. 2 It is based on the same prin- 
ciple as that of the preceding instruments, namely, that the 
tension of a fluid in motion is in proportion to the force 
necessary to arrest the flow. v. Basch and Potain who made 
use of this phenomenon, experimented with an artery of 
medium caliber, while Riva-Rocci in his method used a 
much larger artery for compression — the brachial. The 
instrument consists of three parts, 3 a hollow pneumatic 
cuff, a pair of Richardson inflating bulbs, and a manometer. 
The cuff consists of a rubber tube 3 cm. or more in diameter, 
covered with a non-elastic material, and is supplied with a 
buckle arrangement for fastening it around the arm. 
The inner part of the cuff communicates with the manometer 
by means of rubber tubing and the manometer (Riva- 
Rocci uses a mercury manometer), and the bulbs are also 
connected by rubber tubing. A glass tube 2\ to 3 cm. in 
diameter is placed vertically into a rather large mercury 

1 Tschlenoff, Zeitsch. fur diat. und phy. Therapie, 1900, i, p. 232. 

2 La Presse Medicale, 1899, p. 37. 

3 La Tecnica sfigmomanometrica, Gazetta di Torino, 1897, No. 9, p. 184. 



INSTRUMENTS 49 

container 5 to 6 cm. in diameter. With these dimensions 
the oscillations are so slight (about 1 mm. for 300 mm. of 
Hg.), as to obviate the necessity for correcting errors as in 
the manometer of v. Basch. For use in private practice 
a portable metallic manometer may be used. This connects 
with only a single inflating bulb. The cuff is placed around 
the upper arm (with the buckle arrangement on the out- 
side) and closing the cuff converts it into a genuine airless 
chamber around the arm. The operator palpates the pulse 
in the usual way. The cuff is then inflated by pressing one 
of the Richardson bulbs. With his eye on the manometer 
the manipulator gradually increases the pressure until the 
pulsation is entirely obliterated in the radial (or the brachial 
artery). In order to control the manometric indications, 
care must be taken to stop inflating the bulb the moment the 
pulse is about to disappear. The last reading is obtained 
by means of the second Richardson bulb. The reading 
may also be taken at the moment of the return of the 
pulse. 1 The latter usually gives somewhat lower values. 
Both procedures are advisable for obtaining accurate 
results. The figures represent maximum pressure. Mini- 
mum pressure is derived by noting by palpation the point 
at which the peripheral pulse waves begin to diminish. 
The pressure to which the veins and capillaries are sub- 
jected by this method is said to be not without danger of 
causing cutaneous hemorrhages in the arm and the hand, 
and pain, peresthesias, and other unpleasant effects may 
result. Moxey 2 reports a case of collapse following the use 
of a Riva-Rocci cuff. 

The width of the cuff in the technique under consideration 
has been the source of much discussion. Nearly all authors 
agree that Riva-Rocci's original cuff is too narrow, but 
v. Recklinghausen goes farthest in the width of the cuff 
which he recommends. He finds a width of not less than 
10 to 15 cm. satisfactory, but considers one of 36 cm. most 
useful. Few clinicians use as wide a cuff as this. The in- 
strument is much used to this day, but nearly every operator 

1 Sahli, loc. cit. 2 British Med. Jour., 1906, p. 45 L 

4 



50 



ESTIMATING ARTERIAL BLOOD-PRESSURE 



has added his own modifications to the apparatus, so that 
it is rarely seen in its original form. 

Some of the errors in the method are due to the variations 
of individuals as to the amount of muscle covering the 
vessels under compression as well as upon the degree of 
thickness and rigidity of the arterial walls themselves, 1 
Pachon considers the distance of the artery under compres- 
sion from the region of the pulse a "characteristic and 
illogical feature of the method, which renders it unreliable 
for the determination of maximum values. 

Fig. 14 




v. Gartner's tonometer. 

v. Gartner's Tonometer (Fig. 14). — This and the Riva- 
Rocci instrument are probably the most extensively used 
apparatus in modern studies on arterial blood-pressure. 
On account of the ease of manipulation and the simplicity 
of its mechanism, Gartner's tonometer met with almost 
instant approval from the day of its first presentation 

i Gushing, Boston Med. and Surg. Jour., 1903, p. 250. 



INSTRUMENTS 51 

before the Wiener Gesellschaft der Aerzte, in June, 1899, and 
it was at once introduced into their wards in the Allgemeines 
Krankenhaus by Nothnagel and Neusser, 1 and was favorably 
mentioned by many others. 

The instrument consists of a pneumatic ring, a mercury 
manometer (v. Gartner also constructed a portable metallic 
manometer for use in private practice), a rubber bulb 
and rubber tubing. The air-tight pneumatic ring is lined 
with a thin rubber membrane. The manometer is made of 
glass tube with a bulb in which the mercury is contained, 
the attached scale registers up to 260 mm. Hg. The ring, 
the manometer and the rubber bulb communicate with 
each other by means of T-tubing, the joints being made 
air-tight by means of leather washers. The ring is slipped 
over the second phalanx of the finger and the finger tip is 
blanched either by rolling a small rubber band to the joint 
or by placing the finger tip into a thimble-like compressor. 
The rubber bulb is then inflated and the figures on the 
manometer indicate the force with which the pneumatic 
ring compresses the small digital arteries. The pressure 
is increased until that exercised on the arteries under com- 
pression is greater than the actual blood-pressure. The 
rubber band is now withdrawn (or the cap removed, as 
the case may be), and the finger tip remains anemic; as 
the pressure is slowly and evenly reduced the blood rushes 
back as far as the ring, which prevents its further progress. 
The blood collecting in this area causes an intense reddening, 
and the patient at this moment notices a return of pulsa- 
tion. The method thus differs from those already described 
in employing the principle that it is easier to note the return 
of sensation than the exact moment of its disappearance. 

It has been contended that the advantage of the method 
lies in the fact that the sharpest sense — sight — is here 
employed instead of the less reliable tactile sense, but this 
has at the same time been set forth as a possible source 
of fallacies in making the readings, 2 since investigators 

1 Shaw, Medical News, 1901, Part I, p. 373. 

2 Martin, Munch, med. Woch., 1903, p. 1021. 



52 ESTIMATING ARTERIAL BLOOD-PRESSURE 

differ as to their conception of the return of color in the 
fingers. Some take it at the moment of the appearance of a 
diffuse red, others not until the finger tip becomes deep red. 
In experiments on negroes, for instance, and in all cases 
in which artificial light was used for the experiment, it was 
very difficult to note the exact level at which flushing took 
place. The subjective sensation of the return of the blood, 
too, to the finger often occurs much later than the flushing; 
a difference of 10 to 15 mm. Hg. has been found between 
the reddening and the return of pulsation. 

The size of the ring with regard to the girth of the finger 
has also been a fruitful source of controversary. Selig 1 
holds that not only this but the different fingers as well 
as the corresponding fingers of the two hands, although 
of the same girth, showed variations up to 50 mm. in the 
manometrical record. But these variations are not as 
great as those due to the disproportion between the ring 
and the width of the finger. Nearly all criticism of the 
method is based on this feature as a possible source of error. 2 
The law of hydrostatics, of course, makes it important 
that the hand be held at a level with the heart, v. Gartner 3 
offers the fact that his instrument indicates the variations 
due to the change of the position of the hand with regard 
to the heart as conclusive proof that his tonometer notes 
other changes as well, and that the figures obtained are 
an actual indication of equivalent variations in the force 
of the blood-pressure in the arteries. The figures correspond 
or come close to the absolute values of mean pressure. He 
proved this by experiments on dogs with white tails. Blood- 
pressure was estimated by the direct method and at the 
same time the tonometer was used on the tails. The readings 
of the two were taken at the same time by two different 
observers. The average of maximum and minimum pressure 
by the direct method gave the mean pressure and in each test 
the tonometer gave almost the same figures for mean pressure. 

i Prag. med. Woch., 1906, xxxl, p. 87. 

2 Hirsch, Deutsch, Archiv. flir klin. Med., 1901, No. lxx, p. 219. Selig, 
loc. cit. 

3 Munch, med. Wochenschr., 1900, p. 1197. 



INSTRUMENTS 53 

A practical modification of the tonometer was intro- 
duced by Federn, 1 who, using two rings connected by 
rubber tubing, was enabled to experiment on two fingers 
at the same time. v. Recklinghausen used a wider ring — 
3 cm. in his experiments — on the basal phalanx instead 
of the middle phalanx of the finger. Interesting control 
experiments conducted on the arm and on the fingers often 
showed that only a very slight difference existed between 
the pressure in these two regions. 

v. Gartner's tonometer has been but little used in America. 
The fact that articles are still published abroad, stating that 
the Gartner method was the one employed, is the reason the 
author has devoted so much space to its description. 

Stanton's instrument 2 was one of the first of its kind made 
in this country, and enjoyed almost universal popularity. 
Since Dr. Stanton's death it is no longer manufactured, 
and others have taken its place. 

Erlanger's instrument meets all physiological requirements, 
but is so cumbersome that its adoption for use in office 
practice is out of question. A full description with illustra- 
tions may be found in the Johns Hopkins Hospital Reports, 
1904, xii, p. 59. 

The following instruments are enjoying considerable 
popularity and have the advantage of being readily portable 
and easy of manipulation. 

The Tycos sphygmomanometer (Fig. 15) is a spring instru- 
ment, the blood pressure being indicated by an arrow 
registering on a dial. It is claimed by the makers that no 
comparative test for the accuracy of the instrument is neces- 
sary as the hand on the dial of the sphygmomanometer rests 
on zero of the scale and returns to zero when the instrument 
is not in use. In event of injury, the hand will fail to rest 
on zero when the manometer is not under pressure. Its scale 
ranges up to 260 mm. 

The special cuff which accompanies the instrument 
consists of a pure gum rubber band of standard width, 

1 Wolf, Wien. med. Presse, 1902, p. 1352. 

2 U. of P. Med. Bull., 1902, p. 34G. 



54 



ESTIMATING ARTERIAL BLOOD-PRESSURE 



from one end of which extend two rubber tubes, the bag 
being enclosed in a sleeve of soft durable material. The 
cuff is applied, and to one of the tubes is attached the 
manometer, and to the other the inflating bulb. This 
bulb is so constructed that a control valve at the side 
permits the escape of air, requiring the use of but one hand 




The Tycos sphygmomanometer. 



to raise or lower the pressure. The pneumatic system, 
consisting of the rubber bag with its two tubes and the 
diaphragm chambers of the manometer, is closed when 
the bulb and monometer are thus attached. Squeezing the 
bulb forces the air directly into the rubber bag within 
the sleeve, and from the sleeve as the distributing centre the 
air enters the diaphragm chambers, causing them to expand. 



INSTRUMENTS 



oo 



The diaphragm chambers are coupled to a wheel and a 
pinion by means of a connecting rod. The ratio which this 
wheel bears to the pinion is such, that chamber expansion 



Fig. 10 




The Nicholson pocket sphygmomanometer set up for use. The cuff is 
seen about the upper and middle third of the arm. The air pressure in 
the cuff and on the mercury is produced by the small pump in the operator's 
left hand. The right hand holds a binaural stethoscope over the brachial 
artery in order that the systolic and diastolic pressure may be estimated 
by the auscultatory method of Korotkow. The upper half of the glass 
tube fits into the lower half by a ground-glass joint. The mercury cannot 
escape because of the other valves shown by the handles. 



is magnified twenty times by the hand on the dial. The 
elaborate details of construction are given in the circular 
distributed by the manufacturers. 



J 



56 ESTIMATING ARTERIAL BLOOD-PRESSURE 

The pressure in the cuff is raised beyond the point required 
to compress the artery and the air is then gradually released 
by means of the simple device attached to the rubber 
inflating bulb. The pressure may be estimated by the 
palpatory or auscultatory method, preferably the latter. 

A mercury instrument is far more reliable than an aneroid 
or dial instrument, as it is more accurate and more durable. 
The problem in the construction of mercury sphygmomano- 
meters has been to combine portability with the recognized 
accuracy and durability. Recently Dr. Percival Nicholson 
has devised a pocket sphygmomanometer which meets 
these three requisites. 

New Nicholson Pocket Sphygmomanometer. — This instru- 
ment consists of a metal case which completely encloses 
and thoroughly protects all the metal and glass portions, 
making it very. durable. The lid of the case when raised, 
automatically locks in the upright position, and acts as a 
support for the instrument. Full directions for the technique 
of using the sphygmomanometer accompany the apparatus. 

Some of the advantages claimed by Nicholson for his 
instrument are that it has a movable millimeter scale 
which can be adjusted to the level of the mercury, thus 
removing the error incidental to changes in the mercury 
by barometric pressure and temperature. The use of a 
steel stop cock and flint glass prevents the formation of 
amalgam with the mercury and the employment of a steel 
needle valve gives perfect air release. 

The entire instrument, pump and cuff, fit into a leather 
case which can be easily carried in the pocket. All parts 
are thoroughly protected so that there is little chance of 
damage to the parts. 



III. TECHNIQUE OF ESTIMATING BLOOD-PRESSURE. 

(Auscultatory Method.) 

No matter which mercury instrument one selects, the 
essentials are the same, namely, that when the cuff is joined 
to the manometer and the hand pump is in position, a closed 



TECHNIQUE OF ESTIMATING BLOOD-PRESSURE 57 

pneumatic system is formed. When the pressure in the 
arm band is raised, the same amount of pressure is exerted 
on the mercury in the reservoir. The mercury is forced 
into the manometer tube, and the degree of pressure is 
expressed in the number of millimeters the column of 
mercury is raised above zero. 

Three terms are used extensively in sphygmomanometry : 
systolic pressure, diastolic pressure, and pulse-pressure. 
The systolic pressure is the maximum pressure exerted on 
the vessel wall during a cardiac cycle. The estimation of 
systolic pressure should always be conducted with a wide 
cuff (12 to 14 cm.) as with narrow cuffs there is a great deal 
of variation. If a cuff 3 to 5 cm. wide is employed there 
will be an error of 50 mm. Hg. With a cuff 9 cm. wide 
there is an error of only 10 mm, but with a 12 cm. cuff the 
error is practically nil. 

The pulse pressure, which is the difference between the 
maximum and minimum pressures, represents the inter- 
mittent burden of pressure imposed on the artery by the 
heart's energy in systole in order to force the blood toward 
the periphery and to maintain the circulation (Stone). The 
diastolic pressure then being the pressure in the artery 
due to its own constriction (systole of the artery) during 
diastole of the heart, pulse-pressure indicates the amount of 
pressure exerted by the heart in excess of the diastolic 
pressure. Stone believes it measures the dynamic over 
the potential energy and represents the load of the heart. 
Normally the pulse-pressure is about 50 per cent, of the 
diastolic pressure, the systolic being 130, the diastolic 85, 
and the pulse-pressure 45. 

Auscultatory Method. — This method has won universal 
acceptance in the clinic and in the consulting room and is 
especially applicable to the physician's uses on account of 
the accurate results which it furnishes. It was described 
first by Korotkow in 1906. 

In making blood-pressure estimations the patient may 
lie down or sit upright in a chair, and the patient's right 
or left arm may be used. It is important, indeed necessary, 
that successive readings should be made under the same con- 






58 ESTIMATING ARTERIAL BLOOD-PRESSURE 

ditions, as far as circumstances permit, that is, the time of 
day, and the length of time after meals should be approxi- 
mately the same, the patient should assume the same posture 
and the same arm should be used. A wide cuff having been 
selected, it is applied with an even pressure to the upper 
arm and fixed by means of straps or by folding in the small 
loose end according to the type of cuff employed. The tube 
leading from the pneumatic cuff is attached to the mano- 
meter, the arm placed in full extension and at rest and the 
cuff rapidly inflated by means of the hand pump or some 
similar appliance. 

The amount of pressure exerted should always be above 
that of the actual blood-pressure, in other words, the pressure 
must exceed by 10 or 20 mm. that required to obliterate 
the pulse at the wrist. The degree of pressure having been 
attained, the air is slowly released from the cuff by means 
of a release screw, until the systolic pressure is learned. 

For this purpose the artery at the bend of the elbow, 
slightly to the ulnar side, is auscultated, using a small 
stethoscope, and as the air in the cuff is released, a remarkable 
cycle of sounds will be heard. (Care must be taken to avoid 
all pressure with the stethoscope.) When the artery is 
completely compressed, nothing will be heard, but when the 
pressure in the cuff is decreased so that the blood is per- 
mitted to flow through the artery, the auditory phenomena 
begin, synchronous with each heart beat. The first sound 
which is heard accompanies the first column of blood which 
is forced through the constricted vessel. The sounds are 
heard with each heart beat and may be described as loud, 
clear-cut, snapping. This has been termed the first phase, 
after which, the pressure being slowly and gradually lowered, 
an entirely different series of sounds suddenly presents 
itself. These are murmurs, loud, rough, typical stenotic 
murmurs, synchronous with each heart beat, as are all the 
sounds with this method. This cycle is called the second 
phase. After persisting for a certain length of time, the 
murmurs cease as suddenly as they appeared, and give 
place to a cycle of sounds, which resemble those of the 
first phase, but are not quite so loud. This is the third 



TECHNIQUE OF ESTIMATING BLOOD-PRESSURE 59 

phase. Suddenly these sounds become less clear, and a 
distinct change in intensity is noted together with an 
altered quality, so that the new sound may be described 
as muted or dull. This dull quality marks the fourth 
phase. The muted sounds become still more indistinct 
and distant and gradually cease, and this point is called 
the fifth phase. 

Originally but four phases were described, but later 
Ettinger detected an alteration in tonal quality of the 
third phase in the transition to the disappearance of all 
sounds and this observation having been subsequently 
confirmed, the normal cycle may be said to consist of five 
phases. 

All observers agree that the beginning of the first phase — 
the first sound that reaches the ear — is the systolic pressure. 
With the auscultatory method the figures obtained are gen- 
erally higher than those found with the palpatory method. 
There is some divergence of opinion regarding the point 
that marks the diastolic pressure. The fifth phase, the 
point at which all sounds disappear, is held by Korotkow 
to indicate the diastolic pressure, and with but few excep- 
tions he has been followed in this view by all observers. 
Warfield has been especially active in attempting to prove 
that the diastolic pressure is not at the point of disappear- 
ance of all sounds (the fifth phase) — but that the true dias- 
tolic pressure is recorded when the third tone becomes dull 
— the fourth phase. Normally there is a difference of but a 
few millimeters of mercury between the fourth phase and 
the fifth phase, approximately 6 mm. Hg., but in certain 
diseases notably in cases with high blood-pressures the 
difference may be as great as 16 mm. Hg. Taussig and 
Cook also regard the fourth phase as marking the true dias- 
tolic pressure, and report some careful clinical observations 
to confirm their belief. 

In normal individuals the determination of the diastolic 
pressure is a matter of the greatest ease, but in certain 
cases the fourth phase is totally lacking. Such cases are 
those with inefficiency of the cardiac mechanism. In such 
cases also it may be impossible to obtain accurate systolic 



60 ESTIMATING ARTERIAL BLOOD-PRESSURE 

pressures, as a beat may be heard then no more until the 
mercury drops 5 or 6 mm., then a few more beats are heard, 
then cessation. One is unable to say at what point the 
true systolic pressure is indicated. 

Clinical Significance of the Phases. — Inasmuch as the indi- 
vidual phases bear a definite ratio in health to the pulse- 
pressure, their significance in pathological conditions was 
early studied. Fischer believes the third phase is the most 
important, but he describes certain alterations of the phases 
in various diseases. In anemias, the second phase is long 
and plainly heard, apparently at the expense of the third 
phase, while the fourth phase again is longer than normal. 
In cases of cardiac weakness the second and third phase 
may both be absent, the condition being more serious in 
the first instance, while the presence of the third phase is 
associated with a less grave cardiac lesion. The third phase 
was found to be especially clear cut in cases of moderate 
arteriosclerosis and in plumbism. 

These conclusions are confirmed by Ettinger, who believes 
that absence of the third phase is a valuable sign of cardiac 
weakness. In two cases there was a return of the third 
phase with improvement, and two cases became worse 
coincidentally with the disappearance of the second and 
third phases. In a pneumonia patient there was a sudden 
disappearance of the second and third phases on the day 
preceding death. Howell and the author 1 have also studied 
the length of the phases in various diseases. 

Hints on Estimating Blood-pressure. — Use a wide cuff 
(12 or 14 cm.) and apply it to the upper arm at the level 
of the heart. 

The cuff should fit closely but without compression. 

There should be no pressure exerted by the stethoscope. 

The mercury column should not be broken. With the 
Nicholson instrument this is readily overcome by suction. 
With other instruments it must be shaken down. 

The instrument should not leak, and should hold the 
pressure without any drop in the mercury column. 

1 U. of P. Med. Bull., November, 1910; Amer. Jour. Med. Sci., September, 
1911. 



TECHNIQUE OF ESTIMATING BLOOD-PRESSURE 61 

The patient should be at rest, and when repeated readings 
are made, the conditions should be as nearly the same as 
on previous examinations. At all events the position of the 
patient should be the same, either recumbent or sitting. 

Two or more readings should be made, allowing time 
between the readings for the congestion to subside. 

Individual readings should be made in as short a time 
as is consistent with accuracy. 

When possible, blood-pressure records should be kept. 

Blood-pressure readings are inaccurate when there is 
edema or muscular rigidity. 

Sphygmobolometry. — This term was invented by Sahli to 
indicate a method which would measure the energy of the 
pulse. The method is a complicated one and is open to 
a great many criticisms on the basis of technic alone, if 
not to the criticism that it is fundamentally wrong. The 
author has made some investigations with the pocket 
instrument, and is convinced that nothing is learned by 
this method which is not afforded by a study of the pulse- 
pressure. 



CHAPTER IV. 

NON-PATHOLOGICAL VARIATIONS OF BLOOD- 
PRESSURE IN THE NORMAL MAN. 

Blood-pressure in the normal young adult may be 
said to be systolic 120 to 130 mm. Hg. and diastolic 85 mm. 
Hg. (auscultatory method, wide cuff). Pressures below 120 
mm. Hg. should be considered abnormal and pressures 
above 140 mm. Hg. are also pathologic. Females, as a 
rule, have a somewhat lower pressure than males, but this 
difference is insignificant. There is rarely a difference in 
pressure in the two arms. Jellinek found a variation in 
but 49 of 209 subjects studied. The development of the 
muscles of the arm and the size of the part have no 
influence on blood-pressure. 

Influence of Age on Blood-pressure. — (a) Pressure in 
Children. — The younger the individual, the lower the blood- 
pressure, and in children the pressure varies with age, body 
weight and body length. General rules may be laid down 
as follows: 

1. Blood-pressure increases with age, weight and size. 

2. Blood-pressure varies in children of the same age but 
different height. 

3. The blood-pressure is variable in children of the same 
age but of different body weight. 

4. The sex plays but little part in pressure. It is generally 
from 2 to 5 mm. Hg. higher in boys than in girls. 

5. Blood-pressure is increased after eating, returning to 
normal within two or three hours. 

6. The ingestion of liquid causes a rise in arterial tension. 
This is an exemplification of the physiological rise of pressure 
after filling the stomach of an animal with water. 

7. There is a rise of pressure after exercise and during 
nervous excitement. 



INFLUENCE OF AGE ON BLOOD-PRESSURE 



63 



Observers have found it difficult to take accurate reading 
in a child under three years of age, but in the main, the 
readings of all agree. Trumpp has made a special study 
of pressure in nursing babies (Gartner instrument). The 
normal is about 80 mm. Hg., although the extremes of normal 
may be placed at 90 and 60 mm. Hg. 



Pressure in Mm. Hg. (Riva-Rocci). 











Oppenheimer 






and 




Age. Cook 


Bauchwitz 


Wolfensohn-Kriss. 


Systolic 


Systolic. 


Systolic. Diastolic 


0- 6 months . . 70- 75 


80 




6-12 months 






80- 85 


90 




2- 3 years 






80- 90 


90 


80 74 


Third year 






90-100 






4- 5 years 








107 


83 82 


6- 7 years 










90 82 


8-9 years 










90 88 


6- 9 years 








111 




3-10 years 






95-115 






10-11 years 










98 90 


10-12 years 








112 




12-13 years 










99 95 


14-15 years 










101 96 


14 years 








158 (? 


?) 


16-17 years 










113 105 



(b) Effect of Illness on Blood-pressure in Children. — The 
pressure is higher in bronchitis and in pneumonia, and also 
in colics and in nervous excitability. There seems to be 
no relation, however, between blood-pressure and fever 
of itself. In acute gastro-enteritis there is a drop and in 
chronic gastro-enteritis the pressure is variable. With 
loss of body weight due to malnutrition there is usually a 
coincident lowering of blood-pressure, this occurring espe- 
cially in nursing infants. In general lymphatism there is a 
low pressure. High pressure is the rule in nephritis, and 
this fact serves, according to some observers, to distinguish 
between this condition and lordotic albuminuria, in which 
the pressure is normal. 

(c) Blood-pressure and School Examinations. — Putermann 1 
made some observation (Gartner) on 43 pupils, whose ages 

1 Wien. med. Woch., 1904, p. 265. 



64 BLOOD-PRESSURE IN THE NORMAL MAN 

ranged between ten and sixteen years. His findings are 
interesting, and show that the more advanced pupils had 
higher pulse rate and blood-pressure before the examinations 
than the children of the lower classes. Furthermore, in 
the former the blood-pressure remained higher after the 
examinations, while in the latter it dropped immediately. 

(d) Pressure in Old Age. — Allbutt 1 believes there is a rise 
of pressure in old age due to increased viscocity of the 
blood, and he maintains that arteriosclerosis is the result 
of high pressure and not the cause. He classifies the arterial 
diseases of elderly men into two varieties: (1) those with 
high pressure whose termination is death by apoplexy; 
(2) low-tension death by cerebral softening. Others do not 
regard high blood-pressure and the cardiovascular changes 
as a necessary effect of advancing years and hold that 
increased arterial pressure does not exist unless it has another 
cause such as nephritis and arteriosclerosis. The writer 
believes that the pressure rises somewhat in elderly men, 
but never above 150 mm., unless there is renal or arterial 
disease. 

Influence of Temperament. — The question of tempera- 
ments is, no doubt, of importance in sphygmomanometry, 
but it is difficult to give any definite rule concerning it. It 
is generally supposed that the highly excitable individual, 
with high color in the cheeks and of a neurotic temperament 
has a higher blood-pressure than normal, but I have been 
surprised at the number of times this supposition has failed 
of corroboration. It is no doubt true that the neurotic indi- 
vidual responds more readily and in great degree to certain 
stimuli than do others of a more phlegmatic temperament. 

Periodic Variations in Blood-pressure. — In the experi- 
mental animal, as well as in man, there have been observed 
certain constant, almost rhythmic variations in blood- 
pressure. Respiration plays therein an undoubted part. 

Lewis 2 states that in respiration there may be a fall or 
rise of pressure depending on whether the breathing is 



i Lancet, 1903, i, p. 170. 

2 Jour, of Phys., 1908, xxxvii, p. 233. 



TEMPORA R Y I r A RIA TIONS 05 

intercostal or diaphragmatic, but Erlanger and Festerling 1 
take exception to this and claim that there is a fall during 
inspiration and a rise during expiration, whether the breath- 
ing is slow or fast or abdominal or thoracic. During quiet 
breathing the respiratory waves are generally negligible. 

Quotidian Variations. — Blood-pressure is supposed to 
vary during the day (many millimeters mercury), but 
these variations are so dependent on external stimuli that 
it is not fair to consider them as normal deviations. By 
this is meant that a stated number of individuals under 
the same conditions of observation, would act differently 
and perhaps oppositely to one another, and it would be 
impossible, therefore, to lay down definite rules concern- 
ing diurnal variation which would fit each individual case. 
Mosso 2 has made a special study of quotidian variations, 
which he thinks are absolutely independent of any external 
or psychic stimuli, and some have found pressure highest 
in the forenoon. 

Temporary Variations. — Zabel 3 examined four healthy 
individuals with the greatest exactness, avoiding all con- 
ditions which would be likely to cause changes in blood- 
pressure, and found a great difference in systolic pressures 
taken at various times under exactly the same circumstances. 
The diastolic pressure remained unchanged. These varia- 
tions have received the name psychic lability (psychogene 
Labilitat) and certain investigators conclude that these 
psychic variations have a definite meaning, and indicate 
abnormal excitability (nervousness). A synchronous change 
in diastolic pressure indicates a normal circulatory appar- 
atus, while change in diastolic pressure alone means arterio- 
sclerosis. 

The temporary changes in blood-pressure are explained 
by supposing increased tension of the vessel wall, and it is 
assumed the heart plays but little part in the variations. 
This opinion is based on observations following the appli- 
cation of electricity to the vessel wall, which is followed by 

1 Jour. Exper. Med., 1912, xv, p. 370. 

2 Arch. Ital. de Biol., 1895, xxiii, p. 192. ■ 

3 Munch, d. med. Woch., 1910, p. 2278. 



66 BLOOD-PRESSURE IN THE NORMAL MAN 

a temporary rise in pressure. Increased excitability of the 
vasomotor nerves and increased irritation of the intra- 
cardiac nervous system may also account in some way for 
these variations. 

Rise During Measurement of Blood-pressure. — Compres- 
sion of a large arterial trunk causes rise in blood-pressure, 
and some have raised the objection that during the act of 
compressing the brachial artery the blood-pressure rises 
and one does not obtain true values. It has been shown, 
however, that when the crural artery is compressed for 
ten seconds the response is only 2 cm. water. If the arm 
is compressed more than ninety seconds, the pressure rises, 
and he has found an increase from 140 cm. to 185 cm. water, 
after twenty minutes compression of the arm. Since there 
is some rise, one should make the blood-pressure estimation 
as quickly as is consistent with accuracy. 

Influence of Sleep. — The changes in blood-pressure which 
occur during sleep have been made the subject of some 
research. The very elaborate technique and the care 
required in conducting such observations may be learned 
from the comprehensive article of Brush and Fayerweather. 
Studies were made during the whole course of sleep and it 
was found that the blood-pressure is lower in the late evening 
than in the early morning, and that during sleep pressure 
falls in the first few hours, rising gradually until the subject 
awakes. Although the increase of pressure is progressive, 
it is by no means regular in its ascent, the maximum height 
of which is reached on awakening. These observations 
seem to accord with those of the other observers (Kiesow, 
Walden, von Wagner, Colombo). 

Brooks and Carroll, 1 although not using the great detail 
shown in Brush and Fayerweather 's work, have arrived 
at about the same conclusions. 

Influence of Posture. — When changing from the recum- 
bent to the standing posture, the minimum pressure is 
increased, the systolic but little, the pulse-pressure being 
thus diminished. 

1 Arch. Int. Med-, 1912, x, p, 97. 






INFLUENCE OF MEALS 67 

Erlanger and Hooker 1 have studied the velocity of blood 
with the v. Kries tachygraph and find that the acceleration 
of the blood flow per heart beat is greatest while recum- 
bent, and least when upright. There is an inverse relation 
between the pulse rate, on the one hand, and the pulse- 
pressure and the velocity of flow, on the other. iUtered 
hydrostatic conditions are held as the explanation of the 
pressure changes which accompany changes in posture. 
There is a rise in pressure on standing upright, but when 
the individual is fatigued, or if the subject is neurasthenic, 
a drop of 10 to 20 mm. pressure is seen. 2 

Influence of Meals. — It is difficult to form a correct 
estimate of the effect of taking food on the blood-pressure, 
for there are many factors which render a critical opinion 
hazardous. All the phenomena of digestion — entrance 
of food into the stomach, its transformation, propulsion, 
absorption, etc., supersede one another so rapidly that the 
influence of one cannot be separated from the other. Loeper 3 
has attempted to avoid the inherent source of error arising 
from the chemical changes of the food, its molecular con- 
centration, the amount, the irritant effect, etc. He gave 
a meal consisting of: 100 gm. of beef; 200 gm. mashed 
potato; 1 hard-boiled egg; 1 glass of water; 75 gm. of bread 
containing little salt. 

Blood-pressure readings were made before digestion, 
then at half-hour intervals following the taking of food. 
The three phases of arterial pressure occurring during 
digestion are shown in Fig. 17. 

In three normal subjects examined three constant curves 
were seen: the first consists of an elevation occurring 
immediately after the ingestion of food — hypertension 
immediatement ; the second, of a fall occurring fifteen to 
forty-five minutes after eating — hypotension secondaire; and 
the third, a rise — hypertension tardive. The height of the 
initial hypertension is seen fifteen minutes after eating, 



1 Amer. Jour. Physiol., 1903-04, x, p. 14. 

2 Richardson Medical News, 1903, lxxxiii, p. 340. 

3 Arch, des Mai. du Coeur, 1912, v, p. 225. 



68 



BLOOD-PRESSURE IN THE NORMAL MAN 



while the lowest point is reached about three-quarters of 
an hour to one and one-half hours later. 



Fig. 17 



START 
15 MINUTES 
20 ,, 
25 
SO 

35 ,, 
40 , > 
50 M 
60 ,, 

2 HOURS 

3 >' 

4 i) 

5 ). 


1J 1 | 1 






: A 


is u y X 


A- ■ ~^t 4 - 


T\r -i \- 


J V - - 3 t ^ 


t \ - t 4 7 


17 -X > +^ ^ ->t -fe 


ILX_ ' ± S Z 


- -t 7 ^Az 


-^ / 


\ 7 


± ' i ■ Jl 



Influence of food on blood-pressure. 



The cause of these three phases is explained as follows: 

The intial hypertension is due to distention of the stomach, 
being especially pronounced when large quantities of liquid 
are ingested and persist until the liquid is expelled into the 
intestine. 

The secondary hypotension is due to "hypotensin" which 
arises in the course of digestion. Salt and meat being the 
strongest secretory excitant, cause the lowest tension. 

The secondary hypertension is due to intestinal distention. 

This is most interesting, and inasmuch as the work has 
been very well done, it deserves consideration. Loeper's 
findings are in accord with those of Colombo, Weiss (quoted 
by v. Recklinghausen), and v. Recklinghausen 1 in this, that 
all have found the lowest pressure to occur about an hour 
after eating, at which time digestion is at its height. 

1 Arch, fur Path, und Pharm., 1901, lxvi, p. 78. 



INFLUENCE OF ALCOHOL AND TOBACCO ' 69 

Influence of Alcohol and Tobacco. — (a) Alcohol has been 
found to have no more influence in raising blood-pressure 
than the ingestion of an equal amount of any irritant. 
There is a change in pulse which gives the impression of 
increased force, but as a matter of fact it is felt at the time 
when there is a depression of tension, so that there is a 
lessening of cardiovascular activity." 

It has been found that, when alcohol is introduced into 
the circulation, it has no stimulant action, and in moderate 
doses, such as are given for therapeutic purposes, it is 
absolutely inert as far as its effects on the heart, bloodvessel, 
and arterial pressure are concerned. When there is a change 
in pressure it is usually in the direction of a fall and not of 
a rise. 

Another side of the question is offered by Bachem 1 in a 
study of the effect of wine, beer, cognac, port wine, and 
champagne. He found that even small quantities of alcohol 
speedily raise the blood-pressure, the latter reaching its 
maximum a half hour after ingestion. Concentrated solu- 
tions are more powerful than dilute, and the action is always 
more pronounced when taken on an empty stomach. This 
is especially true of champagne. The cause of the pressure 
action is not vasomotor as Kochmann believes, but is 
purely the result of increased cardiac activity. 

It is only fair to state that in chronic alcoholics hyper- 
tension is frequently seen but this must be ascribed to 
arterial degeneration secondary to the toxic action of alcohol. 

(6) Tobacco has a decided influence on blood-pressure, 
as is shown by the chart (Fig 18). Inhalation brings about 
a decided rise in the neophyte and in the habitue, whereas 
smoking without inhalation has much less effect, and some- 
times none. The action of tobacco is due to the absorption 
of some toxic agent. 

"The rise in blood-pressure is gradual, increases regularly 
until a rise of 10 to 30 mm. Hg. has been established and is 
greatest when ' strong' tobacco is used, and at the time when 
the smoker feels a sensation of definite intoxication. It is 

1 Arch, fur die Ges. Phys., 1906, cxiv, p. 508. 



70 



BLOOD-PRESSURE IN THE NORMAL MAN 



most marked when the smoke of a heavy cigar is inhaled, 
almost as great with an old pipe, and least when the tobacco 
consumed is in the form of a cigarette" (Cook and Briggs). 
The hypertension lasts from one to two hours, after smoking, 
so that a smoker has constantly an abnormally high pressure. 
Janeway is unable to confirm the last statement. 

Fig. 18 





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140 
130 
120 
110 
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Tobacco smoking. (Cook and Briggs.) 

Influence of Exercise. — When exercise is prolonged or 
violent, as in running, football, etc., there is a diminution 
of blood-pressure, but when it is moderate, the pressure 
is always raised. Training influences this a great deal as 
is shown by an interesting report by Pembrey and Todd. 1 
Two men performing the same amount of exercise were 
studied, one of the men being in training and the other an 
untrained man. Both men were made to run up and down 
stairs for half a minute, and it was found in the trained 
man that the pulse-rate was doubled by the effects of exercise, 
but rapidly returned to its normal rate during rest, while 
in the untrained individual, the rate was more slowly 
increased and the recovery was delayed. The blood-pressure 



Jour, of Physiol., 1908, lxvi, p. 37. 



INFLUENCE OF PSYCHIC STATES 71 

of the athlete showed a smaller rise and a more rapid recovery 
than did that of the untrained man, whose pressure often 
fell below the normal even after a rest of five minutes. 
An unique opportunity was afforded Gordon 1 to study 
the effects of exertion on blood-pressure in the champion 
club swinger of the world, who had arranged to swing 
his clubs for twelve hours continuously on six consecutive 
days. Before beginning this feat of endurance, the blood- 
pressure was taken, and measured 100-70. The following 
table will show morning and evening differences in maximum 
systolic pressure taken during the six successive days: 

Riva-Rocci and Erlanger Instruments Were Used. 

Morning. Evening. 

First day 105 109 

Second day 100 115 

Third day 107 115 

Fourth day 100 105 

Fifth day 105 115 

Sixth day 120 125 

As may be seen, there was no noteworthy change in the 
blood-pressure. Gordon made readings also in two players 
in an international Rugby football match. One case fell 
from 145 to 120, and Gordon believes, violent exercise 
depresses blood-pressure, while gentle and moderate exercise 
tends to raise it. Otis 2 arrives at similar conclusions, as do 
Karrenstein, (Gartner 3 ) and Moritz. 4 The latter adds, 
that the more the will and attention is necessary to the 
exercise, the greater will be the rise in pressure. Depression 
of pressure below normal is a sign of cardiac tire, and in 
those unaccustomed to excessive blood-pressure is a good 
indication of how much exercise to permit. 

Influence of Psychic States. — Severe pain increases 
pressure 15 mm. Hg. (see p. 73); sensory stimuli, and a diffi- 
cult mental problem raise it 20 mm. ; animated conversation, 

1 Edin. Med. Jour., 1907, xxii, p. 53. 

2 Amer. Jour. Med. Sci., 1912, cxliii, p. 268. 

3 Zeitschr. fur klin. Med., 1903, 1, p. 322. 

4 Deutsch. Arch, fur klin. Med., 1903, lxxvii, p. 339. 



72 



BLOOD-PRESSURE IN THE NORMAL MAN 



30 mm. ; severe muscular effort 35 mm. If effort is made in 
absence of respiration, pressure falls. 1 

In anger, the pressure has been found by Fere, 2 to rise 
to great heights, and he hints at the detriment and menace 
attacks of cholera are to individuals suffering with disease 
of the arteries. 3 Fere believes anger and epileptic seizures 
are intimately related in their manifestations, and are 
physiologically not to be differentiated. 

Fig. 19 



March 23 


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Rise in blood-pressure produced by mental effort (Erlanger Sphygmogram. 

12 cm.) (Janeway). Chart obtained from Prof. , who lectured 

to a large class from twelve to one o'clock. Before and after the lecture 
he sat quietly in his laboratory. Note the coincident rise in pulse-rate; 
the greater rise in diastolic pressure; the subsequent fall in pressure, with 
decreased pulse-pressure, while the rate remained rapid. 



Janeway has constructed a chart (Fig. 19), showing the 
increase in systolic pressure and pulse-rate, after an hour's 
lecture, a rise which is obviously associated with excitement 
and considerable mental effort. 

It is not an uncommon thing to find the blood-pressure 



1 Binet and Vaschide. Comptes Rend. Acad, de Soc. de Paris, 1897, cxxiv, 
p. 44. 

2 Comptes Rend. Soc. de Biol., 1889, i, p. 368. 

3 See Treatment of Hypertension. 



INFLUENCE OF PAIN 73 

much higher at the first visit of the patient than it is after 
relations are a little less new, and the marked effect which 
psychic states exert on blood-pressure should be watched 
for with great care in order to avoid incorrect interpretations 
of the figures obtained. 

Influence of Pain. — It is difficult to estimate the influence 
of pain on blood-pressure, as one is often unable to exclude 
the influence of the conditions causing it. Some interesting 
observations on the changes in blood-pressure following 
irritation of tender points have been reported. Apart from 
the purely physiologic interest, these studies have some 
practical clinical bearing. Pressure on pain areas is fol- 
lowed usually by a rise in pressure, but two cases are cited 
by Rumuf as typical of a fall. Both were head injuries, 
with painful areas over the skull. In the one, the pressure 
was 180 mm. Hg., but after rubbing the tender spot three- 
quarters of a minute, the pressure sank to 156 mm. Hg. 
The patient had subjective pain for a considerable length 
of time but the pressure rose to 175 mm. Hg. a minute 
after the rubbing has discontinued. The other case showed 
a similar phenomenon: 

At rest . 250 mm. 

Irritation of area 225 mm. 

After rest 250 mm. 

In any event, whether the pressure is higher or lower 
after irritation, the physiological normal pressure is re- 
attained within a very short time. Griitzner and Heiden- 
hain, 1 on the other hand, find no constant phenomena after 
painful stimuli. 

In all these experiments, respiration and muscular con- 
tractions must be taken into consideration as tending to 
influence results. This seems to have been done by Cursch- 
mann, who found by using electric stimuli that there was 
practically always a rise of 8 to 10 mm. Hg. in normal 
individuals (Kiva-Rocci). In patients with functional or 
organic circulatory disease, there was no change in pressure, 

1 Pfliiger's Arch. f. Phys., Band xvi. 



74 BLOOD-PRESSURE IN THE NORMAL MAN 

which was also true in cases of cutaneous paresthesias. 
Curschmann regards the latter observation as a proof that 
hysterical subjects really do have pain in the sense that 
those suffering with organic lesions have true suffering. 

In tabetic crises the pressure has been seen to rise from 
115 to 125 mm. Hg., to 170 to 210 mm. Hg., due to vaso- 
motor spasm arising from the splanchnics. In lead colic the 
same has been observed. In pain, arising from abdominal 
conditions like ulcer, carcinoma, cholelithiasis, etc., the rise 
in pressure is very slight, not more than 10 mm. Hg. 

Influence of Barometric Pressure and External Tem- 
perature. — The following report by Musgrave and Sison 1 on 
some blood-pressure studies undertaken in Manila, shows a 
lower pressure for individuals in the tropics than is found 
in those living in cooler climates. Although explanations 
are not given, the authors believe that splanchnic influences 
may be a prime cause, as abdominal disorders, "tropical 
liver" and "abdominal vacuity" would indicate. Elaborate 
tables may be found in their article. 

The influence of temperature alone seems to have nothing 
to do with blood-pressure. This remains practically the 
same, whether there is rain or shine, whether the tempera- 
ture is high or low, or whether the barometer indicate stormy 
or good weather. When the external temperature is lowered, 
however, after being high (as in bed), the blood-pressure is 
raised. 

Effect of Compressed and Rarefied Air. — In an early 
work on this subject, Dietrich 2 observed that during inspira- 
tion in compressed air there was a rise of pressure in the 
first half of inspiration and a fall in the second half, coin- 
cidently with a smaller pulse curve as shown on the sphyg- 
mograph. The cause of the rise of pressure is to be seen 
in the medium pressure of the intrathoracic vessels, as in 
the Valsalva experiment. (Forcible expiration with nose 
held closed by fingers.) Expiration in compressed air, is 
accompanied by a fall in pressure, so that the pulse curve 
falls below the original base line, finally rising somewhat 

1 Philippine Journal of Science, 1910, v, p. 325. 

2 Arch, fur exper. Path, and Pharm., 1884, xviii, p. 242. 



EFFECT OF COMPRESSED AND RAREFIED AIR 75 

as expiration is concluded. Dicrotism appears and the up 
stroke becomes sharper and higher, all of which indicate a 
rapid fall in blood-pressure. The increased rapidity of the 
pulse is explained on the basis of inhibition by the distended 
lung of the cardiac regulating mechanism. 

In rarefied air, inspiration is more difficult than in normal 
air. Inspiration is accompanied by a slight rise in pressure, 
as under ordinary conditions. Expiration is accompanied 
by rise in pressure, which is especially noticeable toward 
the end of the expiration. 

Muller's experiment (inspiration with nose and mouth 
closed) and Valsalva's experiment (expiration with nose 
and mouth closed) were tried. In the former, there was a 
sudden drop in pressure, followed immediately by a rise, 
which is but an exaggeration of the result obtained during 
inspiration in rarefied air. In the Valsalva experiment, the 
pressure was raised, and the pulse became slower. 

Balloon ascensions have taught us that blood-pressure 
rises parallel to the lowered atmospheric pressure, and 
it is believed that this is purely a physical phenomenon 
and not at all a physiological one. The effects of the 
increased blood-pressure are not felt until there are some 
respiratory disturbances. 1 This view is not generally 
accepted, and fall of blood-pressure has been noted by 
experimenters using the pneumatic chamber. 2 

The difference in reports on blood-pressure during 
mountain ascensions is due to the difference in blood- 
pressure instruments used. Schneider and Hedblom 3 
employed the Erlanger sphygmomanometer, while making 
observations at high altitudes, and they conclude that a 
considerable elevation in altitude tends to lower systolic 
and diastolic pressure and so increases the rate of heart 
beat. There is a greater fall of systolic than of diastolic 
pressure, in fact the latter may be seen to rise in some 

1 Camus: Comptes Rend. Soc. de Biol., 1903, lv, p. 790. 

2 Bert: La pressure barometrique, 1878; Lazarus and Schirmunski: 
Ztsch. fiir klin. Med., 1883; Mosso: Archives ital. de Biol., 1905, lxiii, 
Bartlett: Amer. Jour. Physiol., 1903-04, x, p. 149. 

3 Amer. Jour. Phys., 1908, xxiii, p. 90. 



76 BLOOD-PRESSURE IN THE NORMAL MAN 

individuals, but the longer the individual remains at the 
high level, the more nearly normal do pulse rate and blood- 
pressure become. Persons who complain most of high alti- 
tudes are those in whom the greatest fall in pressure and 
the greatest acceleration in the rate of heart beat are seen. 

Still another view is that of Staehelin 1 who believes that 
rarefied air has no effect on blood-pressure. This opinion 
is based on measurements made on himself during a balloon 
ascension, and while in a pneumatic cabinet. 

Mountain Sickness. — Bartlett 2 transfers to man his ex- 
periments on rabbits, and concludes that there is a fall 
of aortic pressure when the pressure of the rarefied air falls. 
This is accompanied by reduction in the capacity of the 
arteries, and these two phenomena are followed by swelling 
of the lung capillaries and a lessening in the flow of blood 
from the lungs. Hence, in mountain sickness, pulmonary 
stagnation due to equalization of the atmospheric and 
intrathoracic pressures is the cause of the dyspnea and 
asphyxia, both of which symptoms are aggravated by the 
work which one must of necessity do in the high altitudes. 

Influence of Baths. — The subject has been approached 
by Mtiller 3 in a way which seems to disarm criticism. Using 
the broad cuff (15 cm.) and the Riva-Roeci syphygmomano- 
meter, he subjected three healthy men to full baths, with 
temperatures running from 28.7° C. (83.6 F.) to 42.5° C. 
(108.8° F.). 

1. Baths of 33° C. (91.4° F.) to 35° C. (95° F.) and lower 
produced sharp increase in blood-pressure and decrease 
of pulse rate, both being more pronounced the colder the 
water became. Soon after the bath the blood-pressure 
became normal. 

2. Baths, ranging from 33° C. (91.4° F.) to 35° C. (95° F.) 
to 40° C. (104° F.), cause first, an increase in blood-pressure, 
then a fall, and then a rise. Pulse rate is not at all constant. 
At 38.3° C. (100.9° F.) the fall in blood-pressure is most 
pronounced. 

1 Med. Klin., 1909, p. 361. 

2 Amer. Jour, of Physiol., 1903-04, x, p. 149. 

s Deutsch. Arch, fur klin. Med., 1902, lxxiv, p. 316. 



BLOOD-PRESSURE DURING CONVALESCENCE 77 

3. Baths above 40° C. (104° F.) cause gradual rise in 
pressure with increase in pulse rate. 

4. The effect of artificial Xauheim baths depends more 
on the temperature of the water than on carbon dioxide. 
A fall in pressure should be regarded seriously. 

5. Sand, steam, hot air and electric light baths increase 
blood-pressure and pulse rate. 

6. The so-called " Wellenbader" and half baths increase 
blood-pressure. When the patient is very active, the pulse 
rate is increased also, but when the patient remains quiet 
it is decreased. 

7. Douches of any temperature whatever increase blood- 
pressure. 

Miiller cautions that such physical measures bring about 
an increase of w r ork for the heart and special care should 
be exercised with patients who have any organic cardio- 
vascular diseases. Especially does the warning hold for 
functional cardiac disease. Many interesting figures illus- 
trating the summary which is given above, but lack of space 
precludes their reproduction. 

Jellinek studied some soldiers who bathed in the Danube, 
but obtained no uniform result. As a rule, those with 
low pressure showed rise, while those with elevated pressures 
remained unaffected. 

Influence of Menstruation. — There is a fall of about 20 
mm. (Riva-Rocci) when menstruation begins, reaching its 
lowest level at the height of menstruation. The normal 
level is again attained three to four days after the flow has 
stopped. There is an increase in pressure at puberty and 
also at the menopause. 

Blood-pressure during Convalescence. — The blood-pres- 
sure in convalescence has received a great deal of study 
from Oddo. 1 The result of his research makes it apparent 
that during convalescence, hypotension is the rule, except 
in two classes of cases. The one comprises subjects show- 
ing arteriosclerosis, arthritis, nephritis, alcoholism; and the 



1 Bull, de la Soc. med. des Hop., May 5, 1905; Reunion biol. de Marseilles, 
June 20, 1905; Comptes Rend. Soc. de biol., 1905, lix, p. 719. 



78 BLOOD-PRESSURE IN THE NORMAL MAN 

other includes younger subjects exhibiting what Oddo calls 
erethisme cardiaque. The latter term is applied to cases 
with violent cardiac impulse, accentuation of the second 
pulmonic, round and full, rapid, rhythmical pulse. In the 
majority of patients, instability of the blood-pressure is the 
characteristic feature, and this is associated with the common 
clinical observation of instabilty of cardiac rhythm. Exer- 
tion, and even change to the upright position, causes marked 
lowering of pressure. 

The cause of the low pressure is believed to be due to 
asthenia cordis, and also to hypotonicity of the arterial 
musculature; some nerve action plays a role, also. 



CHAPTER V. 
PATHOLOGICAL CHANGES IN BLOOD-PRESSURE 

HYPERTENSION (Hypertensive Cardiovascular Disease). 

We have learned in previous chapters of the vasomotor 
mechanism, by means of which blood-pressure is main- 
tained in health at a definite level, and we have seen what 
changes are brought about by various stimuli, changes 
which, because they occur almost daily, and because they 
are but transient, are generally regarded as non-pathologic 
or functional. In normal man, blood-pressure estimated 
by the auscultatory method, using a standard instrument 
and a wide cuff, may be said to be 130 mm. Hg. (systolic) 
and 85 mm. Hg. (diastolic). Despite the fact that a rise 
in pressure in individuals past fifty is generally supposed 
to be physiologic, the author believes this is never above 
150 mm. Hg. in health. 

Permanent high blood-pressure (above 160 mm. Hg.) 
is met with in but two groups of cases, the one may be 
called simple hypertension or hyperpiesis (All butt) and the 
other is nephritis. Arteriosclerosis is purposely omitted, as 
we believe that the blood-pressure is but only slightly 
raised (140 to 150 mm. Hg.) Whenever a pressure above 
150 mm. Hg. is encountered, no matter what the age of 
the patient, chronic nephritis should be suspected, and 
every means at our disposal should be enlisted before the 
case is classed as hyperpiesis. Schlayer, 1 in a paper on the 
cause of permanent hypertension, quotes some figures of 
Fischer, which show that of 550 patients with permanent 
blood-pressure above 140 mm. Hg., 62.5 per cent, had 
definite signs of nephritis, 14.5 per cent, had a probable 

1 Munch, mod. Woch., 1913, p. 63. 



80 PATHOLOGICAL CHANGES IN BLOOD-PRESSURE 

nephritis, and in 23 per cent, examination was negative. 
Of 300 cases with blood-pressure above 160 mm. Hg., 
80 per cent, showed definite signs of renal disease; in 16.3 
per cent, nephritis was probably present, and in but 3.6 
per cent., there was no reason for suspecting any kidney 
insufficiency. Of the 300 cases, 46 came to autopsy, and 
in all there was a definite and advanced disease of the 
kidneys. Such statistics substantiate the belief that pres- 
sures above normal should be regarded most seriously, 
not prognostically gravely, but diagnostically seriously, 
as nephritis is, in the vast majority of cases, the cause of 
hypertension, despite negative urinary findings. 

Discussion of blood-pressure in arteriosclerosis will be 
found in Chapter VI, and nephritic hypertension will find 
consideration in Chapter VII, while high blood-pressure in 
other conditions will be spoken of in appropriate chapters. 
This limits us to that group of cases known as hyperpiesis, 
by which is meant simple hypertension without signs of 
renal or arterial disease. It has also received the name of 
hypertensive cardiovascular disease. 

Krehl first called attention to this form of hypertension, 
and his experience has been that of all clinicians. 1 To be 
admitted into the class of simple hypertension (known in 
France and Italy under the caption "hypertension arter- 
ielle") there must be no clinical or anatomical evidence of a 
nephritis or of an arteriosclerotic process. As far as the 
latter is concerned, Krehl admits that conclusive evidence 
is almost impossible to adduce, but he states he has seen 
many autopsies with the aorta and mesenteric vessels 
showing much less change than in cases of arteriosclerosis 
with normal pressures. There can be no reasonable doubt 
that such cases of hyperpiesis do occur. 

Janeway 2 has found, that in a small proportion of cases 
(10 to 15 per cent.) with high blood-pressure, cardiac 
hypertrophy and arterial changes, the hypertension is 
independent of nephritis. Butler 3 describes a condition, 

i Deutsch. med. Woch., 1905, p. 1872. 

2 Amer. Jour. Med. Sci., 1906, cxxxi, p. 772. 

3 Practitioner, 1909, lxxxii, p. 854. 



HYPERTENSION 81 

occurring in middle-aged and elderly people, characterized 
by a high blood-pressure, a tendency to moroseness or 
irritability and sudden apoplectiform or epileptiform attacks 
which leave more or less transient nervous symptoms, often 
aphasia or localized paralysis. He is insistent that these 
cases have no sign of arteriosclerosis or of Bright's 
disease. 

As commonly seen when the heart is well compensating, 
the individual (generally over fifty) with hypertension is 
less a patient than a subject whose organism is simply 
under a circulatory regime and fluid equilibrium which are 
different from those existing in the normal state. It is a 
sphygmomanometric disease rather than a true disease. 
(Gallavardin.) 

In this phase of the hypertension, even if the pressure is 
very high (220 to 250 mm. Hg.), there may be no symptoms; 
palpitation and dyspnea may be absolutely lacking. Search 
as one may, the individuals complain of nothing apart 
from perhaps slight dyspnea on going up stairs. They have 
nothing, and they are not patients in the strict sense of the 
word, that is, they are not sick. They have a large heart, 
and the most one can say is, that there is some hidden 
constitutional vice or defect which makes this large heart 
necessary. 

So long as the left ventricle remains able to carry on its 
increased work, all is w T ell. It must be remembered, however, 
that accidents are very prone to occur in hypertensive 
cardiovascular disease. Even when well compensated, 
cerebral hemorrhage is a common danger. The individuals 
are exposed to other cerebral menaces — vertigo, persistent 
headaches. Symptoms of renal disease may appear after 
the least aggravation of the hypertension — uremia. 

When the heart begins to falter in its work, pulmonary 
symptoms are generally the first to appear. Dyspnea on 
slight exertion and acute pulmonary edema may disclose 
itself with no premonitory symptoms. Such an attack 
may be the first abnormal state which makes the patient 
consult a physician, so insidious has the weakening of the 
left ventricle taken place. As the cardiac arrhythmia becomes 



82 PATHOLOGICAL CHANGES IN BLOOD-PRESSURE 

more pronounced, dyspnea of effort is transformed into 
dyspnea of rest, and the patient is always short of breath. 

Gallavardin writes, "but while the dyspneic episodes, 
caused by the faltering of the left heart, are being unfolded 
before our eyes, there is an organ hidden in the chest which 
takes on itself each blow, and which parries each with as 
much strength as lies in its power. This is the right heart. 
Good companion of the left ventricle, it is he, who gives the 
useful blow in return, furnishing the force necessary to 
cleanse the pulmonary field." 

The cardiac signs of the decompensation of the left 
ventricle are first, gallop rhythm, then a functional murmur 
at the mitral area (relative mitral insufficiency), and finally, 
a regurgitant murmur at the tricuspid area. Tachycardia 
is an important sign (80 to 120) extrasystoles are sometimes 
heard, but the pulsus alternans is always present. 

From the standpoint of blood-pressure in this stage of 
hypertension, there is a lowering of pressure, at first momen- 
tary and transitory, but finally becoming progressive. The 
diastolic pressure is generally not lowered any more than 
it is lowered with any fall of systolic pressure. 

During the progress of cardiovascular dissolution, the 
kidneys have suffered in their turn and the condition now is 
cardiorenal and not cardiovascular alone. There is reten- 
tion of chlorids and of nitrogen. Cheyne-Stokes breathing 
appears, insomnia, edema, and finally uremia. 

The pathogenesis of this cardiovascular hypertension is 
not understood. A great many clinicians regard it as a 
latent form of chronic hypertensive nephritis, a nephritis 
without albumin and casts. This is not improbable, and I 
believe albumin and casts are sometimes a very late sign 
of a long-standing nephritis. Be this as it may, autopsy 
fails to reveal aught save a left-sided cardiac hypertrophy, 
with no sign of arteriosclerosis or of nephritis. iVubertin 
and Parva have made a study of the nitrogen in the blood 
serum of these cases but have found no increase, indicating 
that the kidneys are at least functionating well. Syphilis 
and thyroid influences may have an important bearing on 
the etiology. 



HYPERTENSION 83 

Osier regards the high blood-pressure as salutary. This 
is no doubt true, but why should hypertension be salutary? 
What is the condition which so menaces the vasomotor 
mechanism that it must throw out this line of defense? 
Certain it is, that freedom from emotional states, proper 
diet, and rearranged course of life help in keeping the blood- 
pressure within moderate bounds (although the normal is 
rarely reached and never maintained), but this brings us 
no nearer the solution of the questions, what is the cause 
of the hypertension and wherein lies the change in these 
cases ? 

Effect of Continued Hypertension.— Despite the salutary 
nature of high blood-pressure it is always a serious 
phenomenon. The work of the heart is considerably aug- 
mented when blood-pressure has been high for any length 
of time, and as a result, cardiac hypertrophy is the earliest 
and most constant manifestation. Subjectively there may 
be but few symptoms, but sooner or later they appear, at 
first insidiously as headache, cardiac palpitation, dizziness, 
gastric distress, nervousness and finally, more pronounced 
disturbances, such as apoplexy, retinal hemorrhage, blind- 
ness, angina pectoris and acute pulmonary edema make 
their appearance. 

On examination, the hypertrophy is readily detected, and 
there may be early signs of decompensation, mitral insuffi- 
ciency, pulmonary stasis, ventricular extrasystoles, pulsus 
alternans and auricular fibrillation. 

Cause of Death in Hypertension. — Heart failure in conse- 
quence of long-continued arterial pressure, must be reckoned 
among the causes or sudden death in hypertension. The 
heart failure is expressed clinically in arrhythmias, especially 
the pulsus alternans; all arrhythmias disappearing, however, 
when the blood-pressure is reduced. 

Janeway 1 has studied most carefully (no autopsy records) 
the cause of death in 100 cases of hypertension. The 
clinical diagnoses were: 

1 Jour. Amer. Med. Assoc, 1912, lix, p. 2106. 



84 PATHOLOGICAL CHANGES IN BLOOD-PRESSURE 

Chronic nephritis . 79 

Diabetes , 7 

General arteriosclerosis 4 

Coronary sclerosis . 4 

Aortic insufficiency 2 

Aortic aneurysm 1 

Primary myocardial disease 1 

Paroxysmal tachycardia (with secondary myocardial insuffi- 
ciency) 1 

Hypertension without nephritis (evident arteriosclerosis or 

cardiac disease) 1 

100 

The following table shows the classification of 100 cases 
by causes of death : 

Gradual cardiac insufficiency 29 

Uremic convulsions or sudden coma 15 

Chronic uremia 20 

Uremic psychosis 1 

Cerebral apoplexy 14 

Acute edema of the lungs 4 

Angina pectoris 3 

Sudden death (unclassified) 4 

Progressive anemia 2 

Acute pneumonia 4 

Unrelated diseases 4 

100 

The early occurrence of dysnpea in a case of hypertension 
indicates marked danger of cardiac inefficiency, but angin- 
oid pains do not make the prognosis worse than do other 
cardiac symptoms. Complaint of polyuria, nocturnal 
frequency, marked headache, or of visual disturbances, 
especially if the patient be below fifty years of age., should 
make the prognosis very guarded, as uremia is frequently 
the mode of termination in these cases. 



HYPOTENSION. 

It is difficult, at the present stage of our knowledge, 
to state just how low the systolic pressure may fall and 
yet be considered normal. In an individual who has been 



HYPOTENSION 85 

observed over a period of time and in whom one has de- 
termined a uniform pressure, any deviation from this 
standard may, with justification, be regarded as abnormal if 
not pathological. But for the rank and file of individuals, 
it must remain a purely arbitrary judgment, at what figure 
to place the lower limit of normal pressure, and the standard 
thus erected must be regarded as but an individual opinion, 
nothing more. 

Some draw the line between low normal and subnormal 
systolic pressures at 100 mm. Hg. (R. R. 5 cm.) and 90 mm. 
(12 cm. G.). The author prefers using the auscultatory 
method, to place the limit at 120 (mm. Hg.), and pressures 
below this should fall in the category of lowered or low 
blood-pressure. Such a limit is purely experimental, however, 
and observations made with a standard instrument, with a 
uniform method, and under uniform conditions, in many 
thousands of healthy individuals, can alone fix the limit 
with any degree of accuracy. 

The causes of hypotension, or the conditions in which 
hypotension is a phenomenon may be classed as follows : 

1. Acute infections, excepting epidemic cerebrospinal 
meningitis. 

2. Chronic Wasting Diseases. — Carcinoma, tuberculosis, 
cachexia from whatever cause, Addison's disease. 

3. Hemorrhage, drugs, chloroform. 

4. Nervous Diseases. — General paralysis of the insane, 
neurasthenia, after epileptic seizures sometimes in tabetic 
crises, after lumbar puncture, Basedow's disease (at times), 
osteo-arthritis, exhaustion, surgical and anaphylactic shock. 

5. Cardiovascular Diseases. — Tachycardia, dilatation of 
heart, arteriosclerosis (at times), mitral stenosis, decompen- 
sating cardiac lesions. 

6. Blood Dyscrasias. — Anemia, polycythemia with spleno- 
megaly. 

7. Renal Conditions. — Cyclic albuminuria, nephritis (at 
times), amyloid disease. 

8. Intoxications. — Alcohol, tobacco (late), acute adrenal 
insufficiency. 

9. Terminal hypotension preceding death. 



86 PATHOLOGICAL CHANGES IN BLOOD-PRESSURE 

These will all be considered in appropriate chapters. 
There is a lamentable paucity of specific articles on low 
blood-pressure, the subject of hypertension apparently 
having dominated the interest and riveted the attention 
of writers. Any one who includes blood-pressure estima- 
tions in the routine examination of every patient must 
have been impressed with the not infrequent occurrence 
of blood-pressures below 120 mm. Hg., blood-pressures 
lying between 110 and 120 mm. Hg. Less common are the 
pressures lying between 100 and 110, and still more rare 
are those between 80 and 100, but apart from exciting sur- 
prise at the abnormally low tension, the phenomenon seems 
to have been little investigated. It is on account of the 
very brief treatment of the subject, that contributions 
devoted to its explanation or papers dedicated to report 
of cases, are extremely valuable. If one will take the pains 
to collect references to hypertension, he will be appalled 
at the amount of research performed along these lines, 
and will gather the incorrect and hasty impression that 
hypertension is after all the only problem in sphygmo- 
manometry. It can not be denied that a persistent high 
blood-pressure carries in its train more destruction and more 
pernicious damage, and that, therefore, it deserves more 
consideration than does low pressure, yet this seems hardly 
a satisfactory explanation for the neglect which hypotension 
has experienced. 

Its importance and significance in certain surgical con- 
ditions, notably shock, in certain clinical crises, such as 
anaphylactic shock, and its almost constant presence in 
acute fevers or infections we shall speak of in subsequent 
chapters. They are valuable additions to our knowledge, 
no doubt, but in cases other than in the above, in individuals 
who present no apparent organic lesion but who consult 
the physician about symptoms to which the specious 
diagnosis of neurasthenia might be too readily applied, 
hypotension is a subject well worth the study. 

Munzer 1 endeavors to classify his cases of hypotension 

1 Wien. klin. Woch. t 1910, p. 134. 



HYPOTENSION 87 

in groups, and succeeds in forming six. Some of his argu- 
ments for this grouping, and the basis fur his diagnosis 
seem to be dogmatic rather than irrefutably sound. His 
paper nevertheless has this value, namely, that it frankly 
invites criticism, its avowed object being to stimulate 
interest in the subject of hypotension. 

The first of Miinzer's groups is the hypotension seen 
in arteriosclerosis. He believes that this is a common cause 
of low pressure and offers as explanation that the blood 
flows through the large hard vessels, as does a fluid through 
an unyielding tube, there being no periodic distention of 
the vessel wall the tension is lowered. In some instances 
the pressure was as low as 85 systolic, 75 diastolic. A 
common trilogy of symptoms is headache, vertigo, and even 
fainting. 

A second group of cases occurs in what Munzer believes 
to be status thymolymphaticus. Wiesel 1 and later Hedinger 2 
observed hypoplasia of the chromaffin system in cases of 
this kind, and since Schur and Wiesel 3 demonstrated hyper- 
trophy of the chromaffin system in cases of hypertension, 
Miinzer believes one may, by analogy, expect hypoplasia 
to be associated with low blood-pressure. He proceeds on 
insufficient ground, however, to arrange certain cases in the 
category of status thymo lymphaticus. 

The remaining groups of disease associated with hypo- 
tension are orthostatic albuminuria, chronic nephritis, 
paroxysmal tachycardia, and cachectic conditions. 

Hypotension is by no means an uncommon feature in 
arteriosclerosis, as Huchard's reference in the Transactions 
of the Sixteenth International Medical Congress in Budapest 
(1919) will show. The author has such a case under his 
care at the University Hospital Medical Dispensary. 

Thomas MacR., aged sixty-seven years; engineer. Was 
referred from the eye dispensary with retinal hemorrhages 
in the left eye. There is decided arteriosclerosis and urinary 
findings suggesting interstitial nephritis, namely, polyuria, 

1 Virchow's Archiv, 1904, Band 176. 

2 Ztsch. f. Pathol., 1907, i, p. 527. 

3 Deut. med. Woch., 1907, No. 51. 



88 PATHOLOGICAL CHANGES IN BLOOD-PRESSURE 

low specific gravity, albumin, and casts. The blood-pressure, 
which in this case is a variable quantity has been as low as 
115 to 80 mm. Hg. 

Another patient, with marked sclerotic changes in his 
retinal vessels, had a long standing pressure of 95 mm. Hg. 

In a recent paper the author has called attention to a 
certain group of symptoms occurring quite frequently in 
cases of hypotension, and has endeavored to indicate the 
treatment which has been of benefit to such an individual. 
Full case reports exemplify these points. 1 

1 Amer. Jour. Med. Sci., April, 1914. 



CHAPTER VI. 

CARDIOVASCULAR DISEASES, INCLUDING 
DISEASES OF THE BLOOD. 

Valvular Heart Disease. — Aortic Insufficiency. — As a rule, 
in aortic insufficiency, the systolic pressure is high and the 
diastolic is low, thereby increasing the pulse pressure. 
There are marked variations in the systolic pressure from 
time to time, the cause of which is little understood, although 
it is held by some that such variations in other conditions 
are due to hypertonic] ty of the vessel wall. The diastolic 
pressure is generally lowest when compensation is failing 
and has been seen to rise when compensation begins to be 
reestablished. 

The persistence of the fourth phase (auscultatory method) 
is a common phenomenon in aortic insufficiency, although 
it is not a pathognomonic sign, it having been heard in 
bronchopneumonia and in Graves' Disease. The author 
has recently heard a persistent fourth phase in a case of 
arteriosclerosis. In some cases of aortic insufficiency, on 
the other hand, there is no persistency of the arterial sound . 

The blood -pressure in the vessels of the leg and arm in 
health when the patient is recumbent is practically the 
same, but in aortic insufficiency there is a marked difference, 
the pressure in the leg being higher than in the arm. Leonard 
Hill 1 is so enthusiastic about the diagnostic importance of 
this phenomenon that he believes he can pick out the cases 
of aortic regurgitation by it alone. The following figures 
show striking dissimilarities: 

Arm. Leg. 

Case 1 130 195 

Case 2 120 136 

Case 3 150 200 

Case 4 160 240 

Case 5 110 130 

Case 6 118 172 

Case 7 130 220 

Case 8 136 178 

1 Heart,' 1909-10, i, 73. 



00 



CARDIOVASCULAR DISEASES 



Hill calls attention to the great variations which occur 
in the relative size of the dorsalis pedis and the posterior 
tibial arteries, and recommends choosing the larger for the 
measurement of the index. 

These observations have been substantiated by Rolleston 1 
who points out that well compensated cases of aortic 
insufficiency show a greater difference between the leg and 
arm pressures than do cases which have signs of failing 
compensations. Records are given of an interesting case 
of fresh endocarditis in which the leg and arm pressures 
were practically alike. In aortic insufficiency complicated 
with mitral disease, the difference is very slight. 

Aortic Stenosis. — The comparative rarity of this con- 
dition probably accounts for the scant amount of blood- 
pressure research, although the systolic pressure is usually 
normal and the diastolic pressure high, giving rise to a 
low pulse pressure. 

Mitral Insufficiency. — In a well compensated case of 
mitral insufficiency there is no definite change in the' blood- 
pressure. Some writers report an increased pressure and 
some a decrease of tension. 

Mitral Stenosis. — Korke 2 gives figures in 10 cases of pure 
mitral stenosis, and these range from 112 to 138 mm. Hg., 
irrespective of the age of the patient. The majority of 
cases which have come under my observation have had 
subnormal pressures. 

The following table, copied from Gordon, will give an 
idea of the blood-pressure variations in the various valvular 
heart diseases: 



Nature of disease. 


Systolic. 


Diastolic. 


Pulse-pressure* 


Aortic insufficiency 
Aortic stenosis 
Mitral stenosis with 


Very high 

Low 

High 


Low 

Relatively high 
High 


Much increased 
Much decreased 
Decreased 


cyanosis 
Insufficiency without 
cyanosis 


Variable 


Variable 


Variable 



Patent Ductus Arteriosus Botalli.— There are but two 
records of blood-pressure estimation, one of those is by 



Heart, 1912, iv, 83. 



2 Lancet, 1911, ii, p. 154 1 ; 



NON-VALVULAR LESIONS 91 

Miiller 1 and the other the writer reported. 2 Mtiller found 
150 mm. Hg. and the author found 108 mm. Hg. 

Blood-pressure in Decompensation. — In the writer's ex- 
perience decompensation usually brings with it a rise in 
arterial blood-pressure, this being due to the fact that there 
is increased peripheral resistance (chronic passive congestion. 
Decompensating heart cases with increased pressure, show 
a return of the latter to normal with improvement. Lang 
and Manswetowa have found in 17 of 18 cases of mitral 
disease, that during decompensation the pressure rises, 
and with improvement there is a fall. In cases of emphy- 
sema, these changes are especially well marked, while in 
aortic disease and in arteriosclerosis they are less well shown. 

There is no fixed rule, however, in decompensation, as 
the author has had several cases with low pressure during 
the past year. 

Non-valvular Lesions. — Acute Myocarditis.— The occur- 
rence of myocarditis in acute infections, acute articular 
rheumatism, diphtheria, influenza, typhoid fever, scarlet 
fever, would naturally be associated with low pressure, 
due primarily to the action of the toxins on the vasomotor 
centre, and secondarily to their degenerative action on the 
heart muscle. 

Chronic Myocarditis (Chronic Cardiac Insufficiency). — 
There has been an attempt on the part of certain clinicians 
to abandon the use of the term chronic myocarditis, claiming 
that this condition cannot be recognized clinically, even at 
autopsy it being difficult to find pathological changes. 

Chronic cardiac insufficiency (dilatation) resulting from 
overstrain may be associated with high blood-pressure, for 
the retarded circulation causes stimulation of the vaso- 
motor centre on account of the asphyxia. The resulting 
vasoconstriction serves the purpose of raising blood-pressure 
(see Chapter I) thereby relieving the asphyxia of the 
medullary centres, but at the same time increasing the 
work of the heart. It may be seen from the scheme below 
what a vicious circle is now operating: 

1 Correspondbl. f. Schweizer Aerzte, 1905, p. 431. 

2 Univ. Penn. Med. Bull., Dec, 1910, p. 509. 



92 CARDIOVASCULAR DISEASES 

Cardiac weakness 

T I 

Increased cardiac effort Slower circulation 

High blood-pressures through 

T I 

Vasoconstriction 

The more the arteries are constricted, the greater the 
work of the heart, and the more it flags, the more the as- 
phyxia of the centres and the greater the vasoconstriction. 
It is comprehensible that in time the ventricle is unable to 
discharge all its blood at one systole and that stasis and 
ventricular dilatation soon result. The Germans have 
termed this condition "high pressure stasis" (Hochdruck- 
stauung). 

With the auscultatory method, the sequence readings 
may show no phases, or one phase may be lacking, usually 
the second or third, and with these changes, tonal arrhy- 
thmias are quite easily detected. In distinction to the 
functional disturbances there is no variation in successive 
systolic and diastolic readings which is seen in the neuroses. 

Effect of Exercise in Cardiac Disease. — In degeneration 
of the myocardium exercise causes a rise, but this elevation 
is not maintained for any length of time, the pressure 
falling even during the exercise, though not reaching normal. 
During the resting period, the return to normal is lower 
than in health. If the rise after exercise, is but small, 
there is said to be a serious functional deficiency of the 
heart. Valvular diseases are without effect on the pressure 
provided the lesion be slight. When it is great the pressure 
behaves exactly as it does in myocardial degeneration. 
Moritz believes that when the pressure falls below normal 
after exercise it is a sign of cardiac tire (see Chapter IV, p. 
71, Influence of Exercise). 

Cardiac Neurosis. — The diagnosis of a cardiac neurosis 
is as indefinite as is the diagnosis of neurasthenia. A well- 
known English clinician once wrote, "Pseudo-angina is 
pseudodiagnosis," and the same criticism might almost be 
aimed at the diagnosis of "cardiac neurosis." Very little 
has been written about the blood-pressure in this condition, 



CARDIAC NEUROSIS 93 

the only work that of Hochlaus 1 but his work is little 
credited. Howell and the writer have studied some cases 
presenting the same chain of symptoms as the organic 
cases, but in which no organic lesion could be found, and 
those cases we have diagnosed as cardiac neurosis. There 
were marked variations in the systolic and diastolic pressures 
and also in the length of the phases, as apposed to a true 
organic case w r here the readings remained more or less 
constant. Two cases serve to illustrate this point. 

Case I. — 0. E.., male, aged twenty years; dental student. 
Chief complaint: nervousness, palpitation, dyspnea, and 
precardial oppression, with general weakness. On examina- 
tion, the heart was apparently normal. No murmurs, no 
arrhythmia; cardiac outlines normal. The following two 
readings were made within a few minutes of each other: 

I II 

145 first phase 135 \ c , ■, 

120 \ 115/ P e 

110/ 95 second phase 

third and fourth phase 90 third phase 
P. P. 70 P. P. 45 

Note variations in successive systolic and diastolic 
pressures. 

Case II. — Eliz. M., aged tw T enty-eight years. Chief com- 
plaint: cardiac palpitation, dyspnea, indigestion, headache, 
and nervousness. On examination, there were no signs of 
cardiac weakness, no murmurs, and no arrhythmia. Suc- 
cessive readings on the same day: 

I II 

130 117 

115 107 

100 87 

87 85 

77 80 

Here again are to be noted marked variations in systolic 
diastolic pressures, and in pulse-pressure. 

1 Deutsch. med. Woch., 1900, p. 701. 



94 



CARDIOVASCULAR DISEASES 



Angina Pectoris. — During the attacks the pressure is 
generally high, but when the attack is over it may be as 
low as 80 to 90 mm. (Gartner) (Pal.). Janeway believes 
one may diagnose between anginoid pain and true angina, 
the latter being the disease in question if the pressure is 
over 180 mm. (R. R. 12 cm. cuff). 

Auricular Fibrillation. — Experimental studies on cats and 
dogs have been made by Lewis 1 in this interesting con- 
dition, by inducing fibrillation by means of faradic stimula- 
tion of the right auricle. There seems to be no constancy 
in blood-pressure phenomena, although there is most 
commonly an abrupt fall and preliminary rise, amounting 
to a third, or a half, of the extent of the former, and a 
gradually rising curve. Eventually the pressure lies within 
5 or 15 mm. of the original pressure. 

The venous pressure changes but slightly. As a rule, 
the venous and arterial pressures move divergently. Changes 
in both venous and arterial pressures are due to changes 
in ventricular contraction. 






Fig. 20 



... ™^\rjl 



V 



taWife 



\^hjk 



Blood-pressure in experimental auricular fibrillation. 

Clinical observations on auricular fibrillation have been 
conducted by Silberberg 2 using an ink polygraph (Mackenzie ) . 
The inequality of the ventricular beats, producing now a 
strong, now a weak radial pulse, suggests some alteration 
in blood-pressures. And it is true, that the more irregular 



1 Jour. Exper. Med., 1912, xii, p. 395. 

2 British Med. Jour., vol. ii, p. 775. 



AURICULAR FIBRILLATION 



95 



the heart, the greater the difference in pressure. When the 
ventricular rate has been influenced by digitalis, the differ- 
ence does not amount to more than 5 or 10 mm. Hg. The 
latter finding is in accord with the experiments of Lewis, 
to wit, that the blood-pressure changes in fibrillation are 
due to the changes in ventricular rate. 

Fig. 21 



' 



'§k 



'I'll'liWilltili'iiliiii' , 



!0-2 C.C. 
17 BEATS 
4 SEC. 



26 C.C. 

15 BEATS 

4 SEC. 



22-7 C.C 
7 BEATS 
4 SEC. 



23-2 C.C 
7 BEATS 
4 SEC. 



|/^f|#\^ 



Blood-pressure in experimental auricular fibrillation. 

The records of eight cases reported by Silberberg are 
reproduced. 





Blood-measure 


Maximum 








readings 


of 


blood-pressure 


Difference in 


Pulse rate 


ase. 


smallest beats. 


recorded. 


mm. Hg. 


per minute. 


1 


150 




210 


60 


56 


2 


80 




100 


20 


72 


3 


100 




130 


30 


92 


4 


95 




140 


45 


74 


5 


130 




140 


10 


44 (digitalis) 


b 


115 




140 


25 


84 


7 


120 




140 


20 


72 


8 


160 




200 


40 


76 



It is obvious that the ordinary method of estimating 
blood-pressure is quite inaccurate, as in the extreme arrhyth- 



96 CARDIOVASCULAR DISEASES 

mia seen in auricular flutter* each pulse wave has a differ- 
ent pressure. Mackenzie (quoted by James and Hart) 1 says, 
"we gave up the attempt to register the blood-pressure 
in cases of auricular fibrillation, for though some sort of a 
result could be obtained, the result would be expressed by a 
figure, and this would have given an aspect of precision 
which it did not possess and would therefore inevitably 
mislead." 

It has been suggested by James and Hart that to overcome 
the inherent errors of the ordinary blood-pressure estimation, 
one should study the average systolic pressure. To obtain 
this, "the apex and radial are counted for one minute, then 
a blood-pressure cuff is applied to the arm and the pressure 
raised until the radial pulse is completely obliterated; the 
pressure is then lowered 10 mm. and held at this point for 
one minute while the radial pulse is counted; the pulse 
is again lowered 10 mm. and a second radial count is made; 
this count is repeated at intervals of 10 mm. lowered pressure 
until the cuff pressure is insufficient to cut off any of the 
radial waves (between each estimation the pressure on the 
arm should be lowered to 0). From the figures thus obtained, 
the average systolic blood-pressure is calculated by multi- 
plying the number of radial beats by the pressures under 
which they came through, adding together their products 
and dividing their sum by the number of apex beats per 
minute, the resulting figure is what we have called the 
"average systolic blood-pressure." The authors illustrate 
their method by the following observation: 

Brachial pressure. Radial count. 

100 mm 

90 mm 13 = 13 X 90 = 1170 

80 mm. . . . . . . 47 - 13 = 34 X 80 = 2720 

70 mm 75 - 47 = 28 X 70 = 1960 

60 mm 82 - 75 = 7 X 60 = 420 

50 mm 101 - 82 = 19 X 50 = 950 

Apex - 131) 7220 

Average systolic pressure = 55 + 

1 Amer. Jour. Med. Sci., 1914, cxlvii, p. 63. 



FUNCTIONAL TESTS OF HEART 97 

Digitalis in cases of auricular flutter is said to exert its 
beneficial effect by slowing and increasing the force of 
ventricular activity, thereby raising blood-pressure. 

Paroxysmal Tachycardia. — In paroxysmal tachycardia 
there is a fall of blood-pressure bringing about cerebral 
anemia, and this accounts for the weakness, giddiness, 
muscae volitantes, and fainting attacks complained of by 
the patient during the attack. 

Functional Tests of Heart. — The estimation of the 
functional capacity of the heart is a matter which is far 
from being as simple as it at first sight appears. It is a 
matter of the greatest importance and, at the same time, 
one of the greatest difficulty, as, from a purely economic 
standpoint it is a vital question to an individual to know 
just what kind of work he is fitted for, just how much work 
he may do, in what form of exercise he may indulge, all 
without drawing too deeply on the reserve power of the 
heart. As Hirschfelder says, "The important question 
is not what the patient can do in a gymnasium, but what 
he can do or what he can not do in every-day life." A 
patient can estimate to a certain extent his cardiac limita- 
tions, for one often hears the statement, " I do not get short 
of breath on going up stairs, or when walking quietly, but if 
I hurry, I cannot breathe so easily." Therefore he does 
not run up stairs, not does he run for trains. In other 
words, functional tests, which of necessity, are directed so 
as to throw extra strain on the heart, express themselves 
in the physical signs and subjective symptoms of the patient 
almost as distinctly, as in the changes of blood-pressure. 
The functional tests with which we are best acquainted 
have not proven very illuminating. 

Methods Suggested for Testing Cardiac Efficiency. — 1. When 
a subject stands after having been in the recumbent posture, 
there is an increase in pulse rate, generally not more than 
twenty beats per minute. In cases with failing compensation, 
this acceleration is increased, so that the pulse rate rises 
more than twenty beats a minute. A modification of this 
test is noting the decrease in heart beats when the patient 
lies down. Normally, the slowing should be up to thirteen 
7 



98 CARDIOVASCULAR DISEASES 

beats per minute, but in the cases of cardiac inefficiency 
there is little, if any, difference. This test has the obvious 
error that too much depends on physical factors. 

2. Method of Mendelsohn-Graupner. 1 — On the postulate 
that the more functional activity a cell or an organ or an 
organism possesses, the more rapidly and the more com- 
pletely will it replenish its store after being consumed 
during work, Mendelsohn bases his "Erholungsmethode." 
His method consists of making a patient work a wheel, 
which is so arranged that the brake band can be weighted, 
and by turning the wheel a complete revolution (one meter), 
the amount of work done in a unit of time can be estimated. 
Thus, a wheel turned once with a kilogram weight equals 
1 kilogrammeter work. Mendelsohn found that with 
100 to 200 kgm., the pulse rate, which is increased, falls 
immediately to normal (moderate work). After 200 to 500 
kgm., pulse rate is normal in 2 to 3 minutes (large 
amount of work). Over 500 kgm., the time in which the 
heart recuperates depends on the extent and the degree of 
the exercise. In heart cases, mild exercise (25 to 50 kgm.), 
was followed by persistent increase of pulse rate even 
after exercise had been discontinued for some time. This 
method can be modified in various ways, as Cabot and 
Bruce 2 have done. The last named authors who agree 
with Graupner, estimate the amount of work done in foot 
pounds, by having the patient walk up a measured flight 
of steps. 

3. Katzenstein's Test. 3 — Katzenstein has made clinical 
application of the observation of Marey and Weber, namely, 
that ligation of a large artery is followed by rise in general 
blood-pressure. It was thought by the two writers that the 
rise in blood-pressure was due to the relative increase in the 
total amount of circulating blood, but Katzenstein believes 
it to be a result of extra work thrown on the heart by the 
constriction. 

1 Mendelsohn: Verhandl, des Congr. fiir inn. Med., 1901, xix, p. 200; 
Graupner: Berlin. Klinik, 1902, xv, No. 174. 

2 Amer. Jour. Med. Sci., 1907, cxxxiv, p. 491. 

3 Deutsch. med. Woch., 1904, pp. 807 and 845. 



FUNCTIONAL TESTS OF HEART 



99 



The patient must lie quietly for a short while before the 
test is made, and all physical influences are to be removed. 
Both iliacs are compressed with the index or ring-finger 
at the ligamentum inguinale. When pressure is insufficient, 
there is a slight thrill felt, but to compress the arteries 
not a great deal of force is required. The compression is 
to be kept up for two to two and one-half minutes. Katzen- 
stein says he has pressed for five minutes, during which 
time very little exertion was necessary, except in cases of 
arteriosclerosis. Since the blood-pressure does not reach 
normal for ten to twenty minutes there is plenty of time 
to make repeated blood-pressure readings after pressure 
has been released (R.R.) 





Blood-pressure. 


Pulse. 


Normal individuals 


Rises 5-15 mm. Hg. 


Stationary or falls 


Hypertrophy of heart 


Rises 15-40 mm. Hg. 


Stationary 


when it is efficient 






Hypertrophy of heart 


Does not rise 15 mm. Hg. 


Rises 


when it is inefficient 






Mild inefficiency 


Below 15 mm. Hg. 


No change 


Severe inefficiency 


Below 15 mm. Hg. 


Rises 



Levy 1 confirms Katzenstein's observations, but believes 
the results are inaccurate when the test is applied to nervous 
or sensitive patients. Hoke and Mende 2 have found that 
not all healthy individuals react with a rise in blood-pressure 
and a fall in pulse rate, and also, that in severe cases of 
cardiac inefficiency, the method is worthless. They are 
emphatic in their statement that in cases of bad decom- 
pensation the method is too dangerous and should not be 
used. 

4. Method of Herz. — After counting the pulse, the patient 
is instructed to flex his arm, the physician, meanwhile, 
resisting his movements to a certain extent. In health, 
there is but little change in the pulse rate, if any, it is slightly 
increased. In diseased hearts, on the other hand, there is a 
slowing of the beats per minute. The author gives no details 
as to the number of times the movements are to be made. 

1 Ztsch. fur klin. Med., 1906, lx, p. 74. 

2 Berlin, klin. Woch., 1907, p. 304. 



100 CARDIOVASCULAR DISEASES 

5. The author believes 1 that in the auscultatory method 
of estimating blood-pressure we have a fairly good index 
to the work capacity of the heart. 

Those interested are referred to the original papers by 
Howell and the author quoted in the section devoted to 
the description of the auscultatory method. In these papers 
will be found the writer's views regarding the usefulness 
of the phases in estimating cardiac function together with 
cases illustrating the changes the phases undergo in de- 
compensation. 

6. Method of Schott. — Schott 2 makes use of the venous 
pressure, using the method of Moritz and v. Tabora, which 
has been described in the chapter on venous pressure 
Schott constructed an apparatus so that bed-ridden patients 
could perform a certain amount of work, after the completion 
of which blood-pressure is estimated. His observations 
are grouped as follows: 

1. Healthy individuals exhibit very little or no elevation 
in the venous pressure (0.5 cm. water). 

2. Patients with valvular lesions, or myocarditis, with 
moderate subjective symptoms, but who could not be said to 
have decompensation, showed an average rise of 2.3 cm. 

3. Patients who were admitted with decompensation but 
who, under treatment, became so much better that the edema 
entirely disappeared, had a rise of 47 cm. water. 

4. Cases with decompensation, namely, edema, chronic 
passive congestion of liver, albumin, the venous blood- 
pressure rose 7.3 cm. 

It will be seen that the more severe the decompensation 
the higher will be the rise of blood-pressure. 

This method of Schott, while apparently very accurate, 
has the great drawback, that it is of use only in the well- 
equipped clinic, and that its employment elsewhere is 
absolutely precluded. 

The objection to all these methods used for testing the 
cardiac function is that they are not more delicate than the 



Amer. Jour. Med. Sci., September, 1911. 
Deutsch. Arch, fur klin. Med., 1912, cviii, p. 737. 



ARTERIOSCLEROSIS 101 

simpler clinical manifestations, such as respiratory distress, 
cyanosis, decrease in size of pulse, tachycardia, and arrhy- 
thmia. 

Russell 1 believes that the extreme variations of blood- 
pressure seen in the same individual are due to hypertonic 
contraction of the bloodvessel walls, and not to increased 
work of the heart. He claims, therefore, that blood-pressure 
estimates of functional capacity of the heart are fundament- 
ally wrong, although Janeway and Park 2 state that a " hyper- 
tonic contraction of more than 30 mm. Hg. seems improbable 
and of more than 60 mm. incredible during life." 

Arteriosclerosis. — A priori, one would say that arterio- 
sclerosis is a common cause of hypertension, but on closer 
reflection, it must be debated whether arteriosclerosis is a 
cause of high blood-pressure, or if high blood-pressure is a 
cause of the arterial degeneration. Huchard, in his work on 
diseases of the heart and aorta, thinks that arteriosclerosis 
is a cause, while Thoma 3 holds that in an uncomplicated 
degeneration of the arteries, blood-pressure does not rise. 
It remains true, nevertheless, that in cases of arteriosclerosis 
with hypertension, even though clinical signs of a renal 
complication fail, one is not justified in claiming that no 
nephritis is present. On the other hand cases of hyper- 
tension do occur without any kidney lesion, notably in 
Graves' disease, melancholia, neurasthenic states, and dis- 
eases of the central nervous system. This view is substanti- 
ated by Krehl 4 who found at autopsy many cases of high 
blood-pressure with no arterial degeneration (see Chapter 
V). However, nephritis must be considered as the principal 
cause of hypertension, although there are often seen cases of 
arteriosclerosis, who have had during their lifetime, high 
blood-pressure, but who exhibit no pathologic changes of 
the kidney at autopsy. 

Sawada 5 examined 206 cases of arteriosclerosis (R.R.), 

1 British Med. Jour., 1912, i, p. 659. 

2 Arch. Int. Med., 1910, vi, p. 586. 

3 Virchow's Archiv, 1886, civ, pp. 209 and 401. 

4 Deutsch. med. Wochensch., 1905, p. 47. 
6 Ibid., 1904, No. 12. 



102 CARDIOVASCULAR DISEASES 

fixing the limit of blood-pressure in health at 120 mm. 
Of 98 cases of arteriosclerosis having normal heart and 
kidneys, there were 83 with normal pressure, 10 border-line 
cases (120 to 130 mm. Hg.), and 5 with pressures above 
130 to 140 mm. Hg. Only one patient had a blood-pressure 
of 176 mm. Hg., and Sawada was not able to exclude neph- 
ritis in this instance. He divides, purely arbitrarily, arterio- 
sclerosis into three grades, the first with palpable thickening 
of the wall, the second when the artery is distinctly palp- 
able, and the third grade when the vessel has a decided 
pipe-stem feel. 

First group 42 cases . . 3 (120-130) 2 above 130 mm. Hg. 

Second group 42 cases . . 5 (120-130) 2 above 130 mm. Hg. 
Third group 14 cases . . 2 (120-130) 1 above 130 mm. Hg. 

He concludes, since only 12.3 per cent, of arteriosclerotic 
individuals show a slight increase of pressure (130 to 160 
mm. Hg.) that arteriosclerosis alone can not account for 
the hypertension. He believes that values above 160 to 
170 mm. Hg. point definitely to an interstitial nephritis, 
even when there is no albuminuria and no cylindruria. 

The conclusions of Sawada, are those of every one who 
has made routine blood-pressure examinations, and every 
clinician has seen cases of marked arteriosclerosis with no 
cardiac hypertrophy and no evidence of hypertension. 
Brault takes a decided stand in the matter and disclaims 
any influence on blood-pressure of an arteriosclerotic pro- 
cess, insisting that any cardiac hypertrophy which ensues, 
is due to a concurrent nephritis. 

In a careful anatomical study, Hasenfeld 1 has shown that 
arteriosclerosis of the splanchnic vessels is not at all uncom- 
mon, but that there is rarely the degree of degeneration 
which one finds in the aorta, in the vessels of the extremities, 
and in the brain. Arteriosclerosis, even when general, 
brings with it no cardiac hypertrophy unless the splanchnic 
arteries are involved or the aorta above the diaphragm is 
markedly diseased. Hirsch 2 has confirmed fully Hasenfeld's 

1 Deutsch. Arch, fur klin. Med., 1897, lix, p. 193. 

2 Ibid., 1900, lxviii, p. 55. 



THORACIC ANEURYSM 103 

observations and has offered further proof of the correctness 
of the latter's views by reporting 5 cases of marked hyper- 
trophy and pronounced splanchnic arteriosclerosis. 

These views of Hasenfeld and Hirsch have been taken 
exception to, the claim being that no constant relation 
exists between left-sided hypertrophy and changes in the 
celiac and mesenteric arteries. In the vast majority of cases, 
an associated contracted kidney can be held as the cause of 
the cardiac hypertrophy. Arteriosclerosis of the thoracic 
aorta can not be a constant cause, either such changes in 
the aorta with no hypertrophy of the heart, and hypertrophy 
of the heart with no changes in the thoracic aorta do occur. 

Longcope and McClintock 1 constricted the superior 
mesenteric artery or the artery and the celiac arteries, and 
studied the effect on blood-pressure and on cardiac changes. 
The dogs were studied for a period of five months and during 
this time there were no changes in blood-pressure and no 
cardiac hypertrophy. They also say that there can be 
found in man no definite association between sclerosis of 
the abdominal aorta and great splanchnic vessels and 
cardiac hypertrophy. 

If Hirsch and Hasenfeld's views were correct, it would 
have received full confirmation by this piece of experimental 
work, and hence we must regard sclerosis of the mesenteric 
vessels as of little significance in the production of cardiac 
hypertrophy. 

An important sign of sclerosis is said to be the "Stau- 
ungsreaktion." Hertzel 2 compresses the artery in both 
legs and in the arm, and in the other arm he measures the 
blood-pressure. In health there is supposed to be a rise of 
5 mm. Hg., while in arteriosclerosis, the rise is 60 mm. or 
more. The explanation offered is, that in the diseased 
arteries, owing to the congestion induced, there is a com- 
pensatory dilatation with resulting rise in blood-pressure. 

Thoracic Aneurysm. — It is a well-established statement 
which has found its way into every text-book, namely, 
that there is inequality of the pulses not only as to time, 

1 Arch. Int. Med., 1910, vi, p. 439. 

2 Berlin, klin. Woch., 1913, p. 535. 



104 CARDIOVASCULAR DISEASES 

but also as to volume of the artery, in aneurysm. This is 
chimeric in a great many instances, that is, as far as the 
digital perception of changes is concerned, and hence it is 
of most importance that blood-pressure estimations should 
be made to determine whether the differences so often 
noted are imaginary or real. 

The arterial pressure in most cases of aneurysm of the 
thoracic aorta or innominate is either normal or slightly 
raised. As a rule, it is much higher in cases of simple 
dilatation of the aorta, a fact which promises some assist- 
ance in the differential diagnosis of the two conditions. 
In the majority of cases, there is a difference of at least 
5 mm. between the pressure in the two arms in cases of 
aneurysm and in simple dilatation, while a more marked 
difference is equally frequent in both. A difference of 20 mm. 
is common in the two classes of cases and hence there is 
little diagnostic value in comparative blood-pressure esti- 
mations. When a difference of 30 mm. is observed, it 
speaks strongly in favor of aneurysm as against mere 
dilatation of the aorta. 

A difference of 5 or 10 mm. is found more commonly in 
aneurysm than in arteriosclerosis or mediastinal tumor, but 
is found in the last two named conditions so frequently 
that the blood-pressure is of little help in diagnosis. When 
differences of 20 mm. are obtained repeatedly evidence 
is in favor of aneurysm. 

In cases where none of the above named pathological 
conditions is present (arteriosclerosis, aneurysm, mediastinal 
tumor), there is no distinct difference between the pressure 
on the two sides. 

In cases with unequal pressure in the two arms, there is a 
large pupil on the side of the lower pressure and vice versa. 
The unequal pupils are said to be due to inequality in the 
pressure of the opthalmic arteries. 

Anemia. — In anemia, even with great weakness, the blood- 
pressure may remain normal. In anemia due to hemorrhage, 
and in the anemia of cachectic states, the blood-pressure is 
low, but it is more proper to speak of the blood-pressure in 
these cases as a result of the cause of anemia and not a 
result of the anemia itself. 



POLYCYTHEMIA 105 

Polycythemia. — Geisbock 1 presented some cases, in 1904, 
of increase in the number of red-blood corpuscles, asso- 
ciated with arterial hypertension, which he called polycy- 
themia hypertonica. Naegeli in his book on blood diseases 
has accepted this statement as true, and easily explains it on 
the increased viscosity of the blood. Others believe, on the 
contrary, that when hypertension occurs it is an indication 
of arteriosclerosis or nephritis, rather than a phenomon of 
the polycythemia. Moller 2 has collected 59 cases of polycy- 
themia with splenic tumor, in 21 of which blood-pressure 
readings (Riva-Rocci) had been reported. The pressure in 
these cases may be classified as follows : 

9 cases below 130 mm. Hg. 

4 cases between 130 and 150 mm. Hg. 

7 cases between 150 and 180 mm. Hg. 
1 case above 180 mm. Hg. 

Winter published 19 cases of polycythemia, of which, but 
1 had splenic tumor. His findings are tabulated: 

6 cases between 130 and 150 mm. Hg. 

8 cases between 150 and 180 mm. Hg. 
1 case above 180 mm. Hg. 

4 cases no pressure readings given. 

In the 18 cases of Geisbock, 10 were between 180 and 
250 mm., 7 between 150 and 180, and only 1 was below 
150 mm. 

A critical study of all these cases shows no relation between 
the blood-pressure and the erythrocyte count, for some 
patients with very high blood-pressures had fewer red 
blood cells than with small number of corpuscles. 

Moller made a study of all cases of hypertensions coming 
to the polyclinic in Berlin, and found of the 35 patients that 
in 20 instances the erythrocytes were found to be between 
five and six millions. He calls attention to some cases of 
"polycythemia" quoted by the above authors, in which 

1 Deutsch. Arch, fur klin. Med., Band lxxxiii; Verhandl. des Kong, fur 
inn. Med., 1904. 

2 Deutsch. med. Woch., 1908, p. 1888. 



106 CARDIOVASCULAR DISEASES 

there was no higher count than this and recommends that 
the term "polycythemia" be employed when the blood 
count is six millions or more. In only 2 of the 30 cases, 
was this count observed, so there can be no direct relation 
between the number of erythrocytes and the blood-pressure. 
There is very little in the literature concerning what in 
America we understand under the term polycythemia (or 
as it is called variously Osier's disease, Vaquez's disease, 
erythemia, polycythemia with cyanosis, megalosplenic 
polycythemia), a condition characterized by increase in 
the number of red cells, chronic cyanosis, and enlarged 
spleen. The author reported one case, 1 a typical case of 
polycythemia, studied with the auscultatory method. Up 
to the appearance of this paper, no case had been studied 
by this method, and since in anemia the phases are loud and 
clear and well-marked, by analogy it might be anticipated 
that in polycythemia the opposite should obtain. The 
patient William B., came to the dispensary complaining of 
pain in the head and buzzing in the ears. On examination, 
he was found to have chronic cyanosis, splenomegaly and 
chronic cyanosis, and his blood count showed hemoglobin 
100 to 110 per cent., red-blood cells 8,000,000 to 11,000,00. 
The blood-pressure was, on two occasions 128 to 105, and 
114 and 93 respectively, and as far as the phases were 
concerned, our surmise was correct, as there was no differ- 
entiation possible. Instead, the sounds had a sticky quality 
which defies description. At the time we reported this case 
it was the first one on record which had been studied with 
the auscultatory method. 

Watson-Wemyss 2 reports a pressure of 108 mm. Hg. in 
a case of Vaquez's disease. 

An increased number of red-blood cells of itself does not 
cause hypertension. 

1 Goodman and Howell, Amer. Jour. Med. Sci., September, 1911. 

2 British Med. Jour. 1913, i, p. 702. 



CHAPTER VII. 
BLOOD-PRESSURE IN RENAL CONDITIONS. 

It were the greatest folly on the part of the internist to 
erect an anatomical classification of renal conditions based 
on clinical experience alone. Pathologists have long dis- 
puted the anatomical entity of chronic parenchymatous and 
chronic interstitial nephritis, and if they fail to agree on 
the lesion, having every facility of examination at their 
disposal, it seems presumptious for the clinician to diagnose 
one or the other type. Widal has lately advocated a classi- 
fication based on functional disturbance of the kidneys, a 
step forward in the proper direction. He has studied the 
excretion of urinary constituents, and bases his classification 
on the retention of sodium chloride or urea, respectively. 
The first is called chloruremic syndrome, and, clinically, is 
recognized by retention of chlorides and by edema. The 
second is called azotemic syndrome, and consists essentially 
of retention of urea, high blood-pressure, polyuria, and little 
or no chloride retention and little or no edema. 1 

Widal's types may persist to the end as individual types, 
the uremia which develops, being termed chloruremia 
and azotouremia, respectively. Sometimes the two exist 
together, and one sees a blending of the clinical manifesta- 
tions of both. The type, as will be seen, corresponds in 
the main, to the parenchymatous and interstitial varieties, 
but Widal's classification has the merit of naming clinical 
conditions in terms of function and not of structure. One 
is forced, however, at present, to conform to the established 
medical nomenclature, and it will be many years before 
old terms cans be abandoned for new ones. 

1 La Presse Med., November 20, 1912. 



108 BLOOD-PRESSURE IN RENAL CONDITIONS 

Acute Nephritis. — There is a great divergence of opinion 
regarding the blood-pressure in acute nephritis, although 
one is surprised at the dearth of articles devoted to its 
study. Many clinicians believe that the pressure is normal 
or but slightly elevated, but majority hold that hyper- 
tension is the rule. In the early days of an acute attack, 
the cardiovascular system may have undergone no change, 
but usually at the end of the second or third week the 
blood-pressure is raised, and by the end of the fourth week 
there is a definite hypertrophy of the left ventricle, with 
accentuation of the second aortic sound. 

In nephritis, occurring in the course of an acute infection, 
the blood-pressure is apt to be lower than when the nephritis 
arises from no apparent cause. The diagnosis of acute 
nephritis, in the absence of an ascertainable cause, must 
be made with some caution, and one should never cease 
to entertain the belief that it is but an acute exacerbation 
of a latent or quiescent disease. A chronic nephritis is of 
such easy stages that it becomes well established before 
it makes its presence known, and it can well be that some 
of the acute attacks are but an acute inflammation of a 
chronic process. This is illustrated in the case of a young 
woman, aged twenty years, who was referred to me by her 
physician in order to discover the cause of a troublesome 
form of stomatitis, associated with a very offensive odor. 
The blood-pressure was 168-100 mm. Hg., there was a faint 
trace of albumin with but few casts and a low specific gravity 
urine. The heart was enlarged to the left with a decided 
accentuation of the second aortic. Since a year ago, the 
pressure has risen steadily until it is now 180-100 mm. Hg., 
with a slight increase in the amount of albumin, a variable 
number of casts, and the same cardiac changes. Subjec- 
tively, the patient feels perfectly well, is busily engaged in 
teaching, and is in total ignorance of her nephritis. 

Fig. 22 is from a patient who had acute dilatation of 
the stomach complicating pneumonia, from which she 
recovered to succumb to an attack of acute nephritis. The 
blood-pressure, which was continually low during the 
pneumonic infection, fell when the acute gastric dilatation 



ACUTE NEPHRITIS 



109 



appeared, and later became higher and higher until death 
occured in uremia. During the attack of pneumonia, there 



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were no urinary signs and no cardiovascular signs of 
nephritis. 



110 BLOOD-PRESSURE IN RENAL CONDITIONS 

A well marked case of acute nephritis was seen lately 
in the Presbyterian Hospital. The patient was an Italian 
boy, aged eighteen years, admitted July 19, 1913, on account 
of swelling of the face and swelling of the right leg and foot. 
Inasmuch as he had a cut on the right knee, the dispensary 
physician believed the edema to be secondary to an infection. 
The injury dated from one month ago, the swelling in the 
right foot and leg ten days ago, and four days ago his face 
became edematous and he lost his appetite. 

On examination the heart outline was normal, and there 
was no accentuation of the second aortic. The blood- 
pressure was 175-120, and the urine contained many 
granular casts, leukocytes, and much albumin. The phenol- 
sulphonephthalein test gave an output of 25 per cent, in two 
hours. The eye-grounds were negative. 

On July 15, 1913, the edema seemed more pronounced, 
there was a lower amount of urine, and blood-pressure was 
170-100. The left border of the cardiac outline was 1 cm. 
outside of the midclavicular line, the right border at the 
right edge of the sternum, and the upper border at the 
third rib. The second aortic sound was accentuated, also 
the second sound at the apex. 

From July 25, 1913, the condition improved, the blood- 
pressure reached 114-60 on July 31, the cardiac outline 
became normal and the urine contained no albumin and 
no casts. 

This, then, is a case of acute nephritis whose pressure 
fell from 175-120 at the height of the attack to 114-60 
when the clinical manifestations of the disease had dis- 
appeared. 

Chronic Parenchymatous Nephritis. — This is a condition 
which, clinically, cannot be diagnosed with any degree of 
accuracy. Changes in the heart and blood-pressure may 
be entirely absent; at all events they are but very slight 
in comparison to those seen in cases of so-called chronic 
intersititial nephritis. Cases have been described which 
have had edema, albuminuria, and other symptoms of 
parenchymatous nephritis for some time but who have 
had low blood-pressure and no cardiac changes. When the 



CHRONIC INTERSTITIAL NEPHRITIS 111 

stage of secondary contraction occurs, the cardiovascular 
changes become those of interstitial nephritis, in kind, if 
not in degree. Others hold that hypertension in parenchy- 
matous nephritis may be as great as in the interstitial 
variety. This divergent opinion is due to the edema which 
makes accurate blood-pressure estimations impossible. 

I have lately had under my care a young Pole, aged 
twenty-eight years, who was admitted to the Presbyterian 
Hospital complaining of dyspnea and general anasarca. The 
edema began six months ago and increased until two weeks 
ago when the patient had to go to bed. 

The patient was very edematous, exceedingly pale, and 
short of breath. The heart outline was normal; there were 
no accentuations and no murmurs. The blood-pressure 
was 129-80, there were no eye changes, the phenolsulpho- 
nephthalein test was 18 per cent, in two hours. The patient 
remained in the hospital from July 10, 1913, to August 27, 
1913, and left considerably improved. During his stay he 
lost from 178 J pounds to 151 pounds, the heart did not 
enlarge nor did any accentuation of the heart sounds appear. 
The blood-pressure ranged from 129-80, to 104-55, the 
average being about 110. 

This case illustrates low-pressure, and no cardiac changes 
in a long standing case of so-called parenchymatous neph- 
ritis. 

Chronic Interstitial Nephritis. — In the chapter on hyper- 
tension it was stated that whenever a pressure above 150 
mm. Hg. is encountered, no matter the age of the patient, 
a chronic nephritis should be suspected, and every means 
enlisted in order to diagnose this condition or to prove 
that it is not the cause of the hypertension. High blood- 
pressure is such a constant phenomenon in nephritis that 
it may be accepted as a rule that chronic interstitial nephritis 
is nearly always associated with hypertension. The writer 
has rarely seen cases with normal or hypotension, except 
in the terminal stages, and if they do occur, they must be 
looked upon as a rarity. 

High blood-pressure is the earliest and most easily recog- 
nized feature of interstitial nephritis, and is a much more 



112 BLOOD-PRESSURE IN RENAL CONDITIONS 

constant sign than the urinary findings. It is not at all 
unusual to find a urine negative as to albumin and casts, 
but hypertension is rarely absent. 

Hypertension is, therefore, to be regarded always as a 
manifestation of nephritis, and this view must be upper- 
most in the examiner's mind until he can prove that in a 
particular case no nephritis is present. Only until then 
must he look for another etiological factor. Schlayer 1 has 
definitely shown what an important sign of nephritis hyper- 
tension is and Janeway (Chapter V) has found that 79 per 
cent, of 100 patients dying with hypertension had nephritis. 
Only 10 per cent, of hypertension cases occur independently 
of nephritis, according to him. 

As regards the height of the blood-pressure, there is no 
definite rule, it may be as high as 300 mm. Hg., but such 
pressures are unusual, and probably the majority will be 
found to be between 180 and 250 mm. Hg. 

The height of the blood-pressure has little prognostic 
value in its relation to nephritis, but the higher the pressure 
the greater the danger of cerebral hemorrhage and cardiac 
failure. 

"A pressure that is seen to be going steadily up from 
week to week, or month to month, in spite of care on the 
part of the patient and the exercise of his best skill on 
the part of the physician, is naturally, a cause for alarm, 
while one that is stationary, or that under treatment is 
lowered to nearly normal, may make one feel more hopeful 
as to the immediate outlook." 2 

It must not be forgotten that hypertension, in a way is 
to be considered as a compensatory process on the part of 
Nature, and that an increased blood-pressure is required 
to drive the blood through the altered renal structure. The 
output of urine depends on pressure, for cases with high 
pressures excrete more urine than those with lower pressure. 
Finck 3 has studied the daily urine curve, and believes 



Munch, med. Woch., 1913, p. 63. 
Herrick, Osier's System, vol. vi, p. 196. 
La Province Med., 1910, p. 143. 






UREMIA 



113 



there is a constant relation between the systolic pressure 
and the amount of urine excreted. 



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Uremia with coma. (Cook and Briggs.) 

Uremia. — The blood-pressure in uremia may be high or 
low, but hypertension is generally seen. The two charts 
(Figs. 23 and 24) taken from Cook and Briggs L show the 
subjective improvement with a lowered pressure. 



1 Johns Hopkins Hospital Report, 1903, vol. xi. 



114 BLOOD-PRESSURE IN RENAL CONDITIONS 

Fig. 24 





5 ?. „ ■?. - S 8 S S \y S - s s 




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1(50 
150 
140 
130 
120 
110 
100 
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Uremia in chronic parenchymatous nephritis. (Cook and Briggs.) 

Amyloid Kidney. — Janeway 1 reports two cases of amyloid 
disease with pressures of 95 and 90 mm. Hg., respectively. 

The Effect of Intercurrent Infections in Nephritis. — This 
subject has received but scant attention although it is one 
which has practical importance and is worthy of close 
study. In pneumonia the infection seems to have little 
influence on the blood-pressure, the latter remaining above 
normal even when there is marked collapse. The writer 
has had lately an opportunity of observing the effect of 
influenza on the blood-pressure of a young woman. The 
pressure before the influenzal attack was 168-100 mm. Hg., 
and on the first day of the infection the pressure was 205- 
110 mm. Hg., and remained at this figure throughout the 
course of the disease, returning to 170-100 mm. Hg. only 
when the infection had run its course. 

Effect of Decapsulation on Blood-pressure. — I have lately 
had the opportunity to study the blood-pressure in a man 
aged thirty-six years, who was under my care for nephritis 
and who was subsequently subjected to an EdebohFs opera- 
tion. The blood-pressure for the first week under observa- 
tion was as follows: 

November 13, 1913 156-125 mm. Hg. 



November 14, 1913 

November 15, 1913 

November 16, 1913 

November 17, 1913 176-128 mm. Hg 

November 18, 1913 170-132 mm. Hg 



162-134 mm. Hg. 
168-130 mm. Hg. 
173-132 mm. Hg. 



Amer. Jour. Med. Sci., May, 1913. 



CAUSE OF HYPERTENSION IN NEPHRITIS 115 

The blood-pressure averaged, thereafter, between 160 
and 170 mm. Hg. On December 27, 1913, the blood-pressure 
was 160 to 125 mm. Hg. 

The man was operated upon December 31, 1913, and 
from this date until his death on January 17, 1914, the 
readings were: 

January 4, 1914 126- 93 mm. Hg. 

January 6, 1914 117-88 mm. Hg. 

January 7, 1914 119-110 mm. Hg. 

January 8, 1914 120- 99 mm. Hg. 

Jaunary 9, 1914 123-109 mm. Hg. 

January 10, 1914 122- 94 mm. Hg. 

January 11, 1914 125- 87 mm. Hg. 

January 13, 1914 124- 79 mm. Hg. 

January 14, 1914 122- 80 mm. Hg. 

January 15, 1914 114-73 mm. Hg. 

As will be seen there was a marked fall in blood-pressure 
following the operation. 

Cause of Hypertension in Nephritis. — The cause of the 
hypertension which is a common feature of chronic nephritis, 
has puzzled investigators since the time of Bright. Many 
theories, supported by experiments, which at first view, 
seemed incontrovertible, have later been shown to be merely 
theories. One must confess after wondering at and admiring 
the mental ingenuity of investigators, that despite the 
alluring fascination which their hypotheses have, we are 
as yet no nearer actual knowledge than we were fifty years 
ago. The subject is still in the nascent state, and what 
will develop therefrom one can never prophesy. In the 
next few pages will be found a discussion of the more 
important theories which have been advanced to explain 
the use of pressure in nephritis. 

(a) Mechanical Theory of Hypertension. — Opposed to the 
theory of toxicity, is that of pure mechanics, which seeks 
to find the explanation of nephritic hypertension in a 
lessening of the circulation of the kidney, due to glome- 
rular destruction. Traube, in 1856, founded this theory in 
the following words: "A contracted kidney diminishes the 
amount of fluid which is subtracted from the aortic svstem 



116 BLOOD-PRESSURE IN RENAL CONDITIONS 

to form urine, and lessens the amount of blood flowing 
in a unit of time from the arteries to the veins. The mean 
tension of the artery is thereby increased, and the heart 
hypertrophies from overwork due to increased peripheral 
resistance." 1 

Ludwig and Thiry, and others of their school, soon showed 
that neither increased resistance (ligation of both renal 
vessels) nor increase of the amount of fluid raised the blood- 
pressure, and Cohnheim has therefore modified this unten- 
able view of Traube, by offering the theory that it is not 
the large vessels which play the important part, but rather 
the finer vessels which are kept in a chronic state of con- 
traction owing to the urinary stuffs w T hich are brought to 
them constantly (water, urea, sodium chlorid). Cohnheim 
says ligation of both vessels proves nothing, as the organism 
can well take care of this increased amount of blood, but 
in nephritis there is a disproportion between the amount of 
blood and the contracted vessels. 

Alwens 2 using a reconstructed technique, believes that 
the cause of the hypertension is purely mechanical, and 
thinks he had demonstrated that there is increased intra- 
renal pressure, which involves the entire arterial system. 
Chemical and nervous influences are absolutely disclaimed. 

The question of the mechanical theory seems to have 
received its quietus from Senator. 3 The latter produced 
embolism of the smallest renal vessels by injecting liquid 
paraffin into both kidneys. In no case was there a rise of 
the carotid blood-pressure, and Senator says "Herewith 
is the so-called physical theory of hypertension and hyper- 
trophy dismissed once for all," although Janeway 4 found, 
after reducing the kidney substance in dogs that there was 
a rise in blood-pressure which gradually fell before death 
(terminal period). 

1 For full literary references, see article by Janeway on this theme, 
Amer. Jour. Med. Sci., May, 1913. 

2 Deutsch. Arch, fur klin. Med., 1909-10, xcviii, p. 137. 

3 Ztsch. fur klin. Med., 1911, lxxii, p. 189. 

4 Proceedings Soc. Exper. Biology and Med., 1909, vi, p. 109. 



CAUSE OF HYPERTENSION IN NEPHRITIS 117 

Average. 

Before operation, fifteen days 106 

After operation, twenty-one days 127 

Terminal period, 11 days 83 

Another dog which lived gave the following results: Average. 

Before operation, forty-five days 90 

After operation, first period, forty-three days . . Ill 

After operation, second period, twenty-six daj r s .121 

After operation, third period, thirty-one days .... 125 

(b) The Effect of Kidney Extracts on Blood-pressure. 1 — In 1898, 
Tigerstedt and Bergmann 2 published a very extensive series 
of experiments, which appeared to demonstrate the presence 
of a pressor substance in extracts of rabbits' kidneys. The 
substance was found almost exclusively in the renal cortex 
and was present not at all or only to a slight extent in the 
medulla. It could be extracted from the fresh organ by salt 
solution, by alcohol, by fresh blood, and to a less extent by 
cold water. Boiling seemed to destroy its action. The sub- 
stance was non-dialyzable and the investigators, therefore, 
concluded it could not be any of the urinary salts. They 
regarded it as an internal secretion of the kidney which passes 
normally into the circulation and named it " renin. " The 
rise of pressure which followed its injection varied from a 
few millimeters to 25 to 35 mm. Hg., due, they thought, to 
its action on the peripheral nerve centres or on the spinal 
cord. Very small amounts caused as much effect as larger 
doses, and repeated injections produced each an effect as 
great as the first injection. 

In order to demonstrate the passage of this supposed 
pressor substance into the circulation, Tigerstedt and 
Bergman injected blood from the renal vein into the vessels 
of rabbits which had suffered double nephrectomy. A 
moderate rise followed (18 mm. Hg.) These last experi- 
ments were repeated by Lewandowsky 3 and although a 
rise of pressure was observed, he obtained similar transient 
pressor effects in his controls by injecting blood from the 

1 The author is indebted to Pearce (Arch. Int. Med., 1908, ii, p. 77) for 
much of the material of this section. 

2 Skand. Arch, fur Physiol., 1898, viii, p. 223. 

3 Ztsch. fur klin. Med., 1899, xxxvi., p. 535. 



118 BLOOD-PRESSURE IN RENAL CONDITIONS 

general venous (jugular vein) and also arterial systems. 
Lewandowsky concludes there is some pressor substance 
in the blood, but he does not share Tigerstedt and Bergman's 
theory that it is an internal secretion of the kidney. Sub- 
sequent investigators have repeated Tigerstedt and Berg- 
man's work with indifferent success. 

Pearce has subjected the research to a critical review, 
and points out the striking fact that the result obtained 
seems to depend on whether or not the kidney extract was 
injected into an animal of the same species. His own 
experiments offer no support to the theory that a pressor 
substance or substances exist in the normal kidney. It was 
found that the injection into the rabbit of extract of either 
dog or rabbit kidney caused a slight rise in pressure but 
that similar injections into the dog caused a depressor 
effect, which, when dog's kidney was used, was very decided. 
It is evident, therefore, that the pressor substance of 
the kidney of any given species has no constant pressor 
effect for animals of other species, as is the case with adre- 
nalin. Almost any substance, blood-serum, defribrinated 
blood, urine, extracts of the liver of both rabbit and dog, 
urea, sodium chlorid and Locke's solution when injected 
into the rabbit's circulation in doses of from 1 to 3 c.c, 
caused a slight transient rise in pressure. Pearce concludes 
that, since there is a rise in pressure by such a variety of 
substances, the effect of the injection is largely mechanical. 

Bengel and Strauss 1 apparently without being aware 
of Pearce's work, have reached the conclusion that there is 
in the kidney a pressor substance which is different from 
adrenalin in its action, being influenced by section of the 
vagus or sympathetic, or by the destruction 'of the spinal 
cord, or even by extirpation of the kidneys, adrenals, and 
liver, and they assume that its action is solely on the mus- 
culature of the arteries. They confirm the work of Tiger- 
stedt and Bergmann, and believe that "renin" must have 
some bearing on the rise of blood-pressure seen in cases of 
contracted kidneys, although they insist that their work has 
shown nothing to prove this assumption. 

1 Deutsch. Arch, fur klin. Med., 1909, xcvi, p. 476. 



CAUSE OF HYPERTENSION IN NEPHRITIS 119 

(c) Adrenalin Theory. — Owing to the frequent occurrence 
of circumscribed or diffuse hyperplasia of the adrenals in 
cases of contracted kidney, Vaquez and Aubertin 1 suppose 
that there is some intimate relationship between the neph- 
ritic process and this hyperplasia, which they believe is 
synonymous with hyperadrenalism. The French school 
has been most actively engaged in pointing out this striking 
occurrence, especially in cases where the disease has had 
a more or less chronic course. Pearce 2 has given the matter 
considerable attention and finds very definite and fairly 
constant changes in the adrenals in general arteriosclerosis 
from whatever cause, interstitial nephritis, parenchymatous 
nephritis, and general arteriosclerosis with no evident 
renal lesion. He believes that the alterations described 
by Vaquez and his followers are not peculiar to chronic 
interstitial nephritis, but are found in all conditions with 
advanced arteriosclerosis. Pearce concludes that a cor- 
relation existing between the diseased kidney and the 
adrenals and having an influence on the vascular system 
is doubtful. 

In May of 1907, Schur and Wiesel 3 discovered that the 
serum of a nephritic caused mydriasis of the enucleated 
frog's eye (Ehrmann's Test) and later w r ere able to prove 
chemically that the blood-serum contained adrenalin, by 
applying the fertic chlorid reaction. On these findings they 
assumed that in nephritis, certain substances were retained 
which acted as a secretary excitant to the adrenals, and 
that the outpouring of increased amounts of adrenalin 
explained the associated hypertension. The Ehrmann test 
was positive in practically all cases of nephritis, and was also 
present in animals with double nephrectomy, and, to a less 
extent, in animals with experimental nephritis. 

Schlayer 4 has repeated the work of Schur and Wiesel, 
using the method of Meyer. Meyer, be it remembered, 5 

1 Bull. Soc. Med. d'hop. de Paris, 1905, xxii, p. 705. 

2 Arch. Int. Med., 1908.. ii, p. 77. 

3 Wien. klin. Woch., 1907, p. 1202. 

4 Deutsch. med. Woch., 1907, p. 1897. 
« Ztsch. fur Biol., 1906, p. 352. 



120 BLOOD-PRESSURE IN RENAL CONDITIONS 



found that arterial walls (vessel strips) could be preserved 
for a long while, and could be used to study the action of 
various chemicals on smooth muscle fibre, and on the nerve 
endings in the vessel wall. One end of the vessel strip is 
fixed, and to the other end a ligature is fastened, armed 
with a point which writes on the smoked drum of a kymo- 
graphion. He found that adrenalin in dilutions of 1 .000,000 
to 100,000,000 could be detected by this method (0.000015 
mg. in 15 c.c. Ringer's solution). Using the Meyer method, 
Schlayer observed a strong contraction of the vessel wall 
with normal human blood-serum, but not with beef serum. 
Further studies revealed to him a decided analogy between 
adrenalin and this unknown pressor substance. 

Turning his attention to nephritis, he held the view, 
that if there is really an adrenalinemia in nephritis, it must 
run quantitatively, pari passu, with the degree of arterial 
pressure. Eight cases were studied (pressure 190-260 mm. 
Hg.), and in all, 26 observations were made. His results 
are given in the accompanying table: 









Contraction 


3i the artery 




Type of nephritis. 


Blood- 
pressure. 


in mm. 


No. 












Nephritic 


Normal 








serum. 


serum. 


4 


Primary interstitial 




195 


32 


25 


13 


Lead poisoning 


110 


50 


23 


10 


Lead poisoning 


212 


25 


33 


17 


Lead poisoning 


208 


12 


17 


5 


Primary interstitial 


260 


18 


34 


6 


Secondary interstitial 


190 


10 


29 


9 


Secondary interstitial 


200 


31 


35 


20 


Secondary interstitial 


195 


26 


28 


15 


Secondary interstitial 


190 


11 


23 


11 


Secondary interstitial 


209 


15 


22 



It will be seen that of the 26 experiments, the nephritic 
serum caused a stronger contraction than normal serum 
in but two. The other cases showed lower pressor 
powers of the nephritics than of the control sera. That 
it was not owing to the dilution caused by the hydremia, 



CAUSE OF HYPERTENSION IN NEPHRITIS 121 

was proved by using the dried residue, but with the same 
result. Schlayer concludes that there is no evidence to 
prove the relationship between hypertension of the adrenalin 
content of the blood serum. Later authors, among whom 
may be mentioned Frankel, 1 Aschoff and Cohn, 2 Oben- 
dorfer 3 have also been unable to confirm Sehur and Wiesel's 
findings. Ingier and Schmorl 4 have studied the epinephin 
content of the adrenal's certain diseases and have demon- 
strated larger amounts in chronic nephritis, true and arterio- 
sclerotic contracted kidneys, than in other conditions. 

That there is a pressor substance in the blood-serum of 
nephritics there can be no doubt, the only question which 
seems vital at the present time is whether that substance 
is epinephrin. 

Stewart 5 insists that no single method should be used 
as evidence of adrenalinemia, and he suggests, in order to 
diminish the chance of error in testing blood for adrenalin, 
to use a combination of bloodvessel and intestines, as adrena- 
lin causes contraction of the former and inhibits contraction 
of the latter. He thinks there is no detectable amount of 
adrenalin in normal blood, and in a second paper 6 he found 
no indication of adrenalin in pathological sera. 

After making comparative studies with the vessel strip 
method, the Lawen-Trendelenburg method and the intestinal 
method, O'Connor 7 finds that while there is a pressor sub- 
stance in the blood, it is certainly not adrenalin. Further- 
more, he discovered that this adrenalin-like body was not 
found in natural blood, but arose during the process of 
clotting. In rabbits, adrenalin could be detected in the 
blood of the suprarenal vein where it was present in dilutions 
of 1 to 1,000,000 or 1 to 5,000,000. Section of the splanch- 
nics markedly diminished the amount of adrenalin. 8 

1 Arch, fur exp. Path, and Pharmakol., 1909, Band lx. 

2 Verhandl. d. path. Gesellsch., 1908, p. 131. 

3 Ibid., 1909, p. 273. 

4 Deutseh. Arch, fur klin. Med., 1911, Band 104. 

5 Jour. Exp. Med., 1911, xiv, p. 377. 

6 Jour. Exp. Med., 1912, xv, p. 547. 

7 Arch, fiir exp. Path, and Pharmakol., 1911-12, xlvii, p. 195. 
s Ibid., 1912, xlviii, p. 383. 



122 BLOOD-PRESSURE IN RENAL CONDITIONS 

Janeway and Park 1 working with a technique which 
embraces a modification of the Meyer method, by using 
carotid and coronary arteries as controls, have found there 
is no evidence that epinephrin exists in the circulating blood 
in amounts sufficient to produce its physiologic effects. 
An exception to this is the suprarenal vein which always 
contains it. The quantity of epinephin required to cause 
minimal hypertension is at least ten to twenty times the 
amount secreted by the adrenal glands. 2 

Despite the fascination which the adrenalin theory seems 
to have, one is forced to admit that there is no just ground 
for assuming that adrenalin is the substance which raises 
the blood-pressure in nephritis. Until Janeway and Park's 
work appeared, many were inclined to the view that the 
pressor substance was an epinephrin-like body, but even 
this last straw is washed away in the flood of evidence 
offered in their research. The substance, whatever it is, 
will doubtless prove to be a very familiar body, in all prob- 
ability a well-known component of the protein molecule. 
This has been hinted at in the work of Lindemann 3 who has 
produced renal changes by the injection of serum from a 
nephritic animal into a normal animal, and is suggested 
also in the work of Pearce. 4 

Hess and Wiesel 5 have shown that injections of adrenalin 
will prevent the death of rabbits poisoned with uranium 
nitrate. 

(d) Hypertension and Blood-sugar. — Working on the knowl- 
edge that adrenalin can cause diabetes (adrenalin diabetes — 
von Noorden) some have assumed that if it is an abnormal 
adrenalinemia which causes the hypertension, then hyper- 
tension must be associated with hyperglycemia and glyco- 
suria. Neubauer 6 has found in a number of uncomplicated 
cases of nephritis, a hyperglycemia, so that there was a 



1 Jour. Exp. Med., 1912, xvi, p. 541. 

2 Haskins and McClure, Arch. Int. Med. 1912, x, p. 343 

3 Ann. de PInst. Pasteur., 1900, xiii, p. 49. 

4 Arch. Int. Med., 1908, ii, p. 77. 

5 Wien. klin. Woch., 1913, p. 317. 

6 Biochem. Ztsch., 1910, xxv, p. 284. 



DOUBLE NEPHRECTOMY 123 

definite relation between the blood-sugar content and the 
high blood-pressure, the greater the hyperglycemia the 
greater the hypertension. These observations have been 
emphatically denied by subsequent workers, notably 
Stilling, 1 Weiland 2 and Tachau. 3 

Hagelberg 4 endorses, however, in no uncertain manner 
Xeubauer's observations, finding not only a hyperglycemia 
but an alimentary hyperglycemia in nephritis and believes 
that in arteriosclerosis and in nephritis there is an increased 
adrenalinemia. 

Orthostatic Albuminuria. — The constant low pressure 
which is seen in postural albuminuria serves in the majority 
of cases to distinguish it from true nephritis. 

Double Nephrectomy. — Extirpation of both kidneys is 
without effect on blood-pressure. 5 The explanation offered 
is that normally there is a hypertensive substance in the 
blood which is eliminated in the urine. The double neph- 
rectomy causes a retention of such a substance and, hence, 
hypertension. Physical factors play no role as there is less 
work on the left ventricle owing to the elimination of the 
glomerular circulation, and the blood-pressure, theoretically 
at, least should be lowered. 

1 Archiv. fur exp. Path. u. Pharmakol., 1911, lxvi, p. 238. 
2 Zentralbl. fur d. ges. Phys. u. Path. d. Stoffw., 1910, p. 13. 

3 Deutsch. Arch, fur klin. Med., 1911, p. 102. 

4 Berl. klin. Woch., 1912, p. 1877. 

5 Mosler Ztsch. fur klin. Med., 1912, lxxiv, p. 297. 



CHAPTER VIII. 

ACUTE AND CHRONIC INFECTIONS INCLUDING 
CERTAIN INTOXICATIONS. 

Some years ago it was prophesied that but very little 
of importance would be obtained from a study of blood- 
pressure in acute diseases. We shall see that such a forecast 
meets refutal in two notable instances, typhoid fever and 
pneumonia, so it would be hazardous to say that, because 
in the vast majority of acute fevers nothing as yet has been 
brought forward, the future will not reveal some valuable 
diagnostic or prognostic phenomena. The fact remains, 
however, that many acute diseases, are, as a rule, uninterest- 
ing from the stand-point of blood-pressure, but the probable 
explanation of this is that they have not been so closely 
studied as have pneumonia, typhoid fever and cerebro- 
spinal meningitis, for instance. 

ACUTE INFECTIONS. 

Typhoid Fever. — Typhoid fever, owing to the danger of 
fatal complications, offers opportunity for the judicious use 
of the sphygmomanometer. In the large cities, the disease 
has become so rare, that it does not possess the same signi- 
ficance as it formerly did, but the complications are never- 
theless ubiquitous, and should be as closely watched for 
as before. All authors are agreed that typhoid fever is 
associated with arterial hypotension, and the figures of 
Crile 1 are of interest in snowing the pressure during the 
course of the infection. 115 cases were studied with the 
Riva-Rocci instrument and of these: 

The highest pressure was 138 mm. Hg. 

The lowest pressure was 74 mm. Hg. 

The mean pressure was 104 mm. Hg. 

1 Jour. Amer. Med. Assoc., 1903, xl, p. 1292. 



ACUTE INFECTIONS 125 

During the course of the disease the mean pressure was 
found to be as follows: 

F'irst week 115 mm. Hg. 

Second week 100 mm. Hg. 

Third week 102 mm. Hg. 

Fourth week 90 mm. Hg. 

Fifth week 98 mm. Hg. 
Cook and Briggs 1 claim that there is no pathological con- 
dition apart from shock, in which careful blood-pressure 
readings are prognostically more significant. They point 
out that the arterial hypotension rises pari passu with the 
degree of the toxemia, a fact beautifully illustrated by Crile's 
figures. Blood-pressure estimations should be recorded as 
frequently as the temperature respiration and pulse rate, 
and the readings should be made a part of the nurse's 
duties as well as the registration of these other clinical 
data. The technique is comparatively simple and it would 
be a great step forward, clinically and scientifically, to have 
this suggestion become a realized fact. Jt is obvious that 
blood-pressure cannot be taken by the physician as often 
as the temperature pulse and respiration are recorded, 
and hence this office must fall to the nurse. 

The significance of blood-pressure in typhoid and indeed 
in many conditions, can only be appreciated when one has 
had previous daily and perhaps, hourly records with which 
to compare deviations. Isolated readings are valueless, 
Gumprecht 2 has shown that individual quotidian variations 
occur as they do in health. 

Hemorrhage. — It is often essential and sometimes difficult, 
to distinguish between intestinal hemorrhage with pain, 
and peritoneal irritation, if not actual peritonitis, and it 
is here that blood-pressure estimations will be found of 
vital importance. Hemorrhage is generally accompanied 
by a fall in pressure as is well shown by the chart reproduced 
from Cook and Briggs, although this is not a constant 
feature. The author has latelv seen a case of fatal hemor- 



1 Johns Hopkins Hospital Reports, 1908, xi, 

2 Ztsoh. fur klin. Mod., 1900, xxxix, p. 877. 



126 



ACUTE AND CHRONIC INFECTIONS 



rhage, but with no fall of blood-pressure below the former 
limit of hypotension (98 mm. Hg.). 



Fig. 25 





2 

£ s | s s s is s 1 * ^ ~ - = ^ ^ - ^_ - 




MM HG 

170 

160 

150 

110 

130 

120 

110 

100 

90 

80 

70 

60 

50 

10 
















































PULSE 

120 
110 
100 

90 

80 

70 

GO 

50 

40 

50 

20 

10 




















































































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Typhoid fever — intestinal perforation. (Cook and Briggs.) 



Perforation. — Just as hemorrhage is usually followed by 
a fall in pressure, perforation is generally associated with a 
sharp rise. Lately a case of perforation was observed which 
fell from 124 mm. Hg. to 110 mm. Hg., and remained there 
until operation was performed. Hypotension of itself is, 
therefore, not a safe indication that there is no perforation. 

Crile quotes five cases of perforation. The first showed 
a rise from 116 mm. to 190 mm. in four hours. The second 
case was admitted with general peritonitis and a pressure 
of 105, later falling, with general improvement, to 80. 
On the eighth day, peritonitis set in and the pressure rose 
from 84 to 100 mm. Hg. In a third case with slowly forming 
perforation the blood-pressure rose from 116 to 165 mm. in 
two hours, but with but little increase in pulse rate. 



ACUTE INFECTIONS 



127 



In cases 4 and 5 the pressure was 165 and 208 respectively. 
Twenty of Crile's cases of acute peritonitis gave the 
following pressures: 

Highest 208 

Lowest 156 

Mean 166 

Fig. 26 





A.M. 
P.M. 

P.M. 

P.M. 

8 P.M. 
9 

12 M. 

5 A.M. 

9 " 

10 " 
12 N. 
2P.M. 




MM HG 

190 

180 
170 
160 
150 
110 
130 
120 
110 
100 
90 
80 
70 
60 














































PULSE 

no 

130 
120 
110 
100 

90 

80 

70 

60 

50 

10 

30 

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Typhoid fever — intestinal hemorrhages. (Cook and Briggs.) 

Cook and Briggs report similar experiences and state 
that "A sharp and well maintained rise in blood-pressure 
in typhoid fever, from a previously known low level, is a 
valuable sign of intestinal perforation, and is probably 
of more constant value than the notoriously uncertain 
increase in the leukocyte count." They question the nega- 
tive value of a rise in systolic pressure in doubtful cases 
with suggestive abdominal signs. 

Late Effect of Typhoid Fever on the Heart and Vessels. — 
Thayer 1 examined 183 patients who had had typhoid fever 

1 Amer. Jour. Med. Sci., 1904, cxxvii, p. 391. 



128 



ACUTE AND CHRONIC INFECTIONS 



from one month to thirteen years previously, and his results 
are well shown in the accompanying table. 



220 mm 



510 mm 



200 mm. 



190 mm 



180 mm, 



170 mm 



160 mm. 



150 mm 



140 mm 



130 mm 



120 mm 



110 mm 



old 113.2 

TYPHOIDS (4 CASES) 



HEALTHY 105.5 

INDIVIDUALS (32 CASES) 



1-10 10-20 



Fig. 27 
20.30 30-40 



40-50 



50-60 60-70 



























































































































































































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134.9 

(28 CASES) 

128.3 

(62 CASES) 



152.2 

(32 CASES) 



135.1 

(52 CASES) 



169.9 

(2-1 CASES) 

139.8 

(19 CASES) 



168.7 
(a cases) 

145.2 

(11 cases) 



183.5 215 

(2 cases) (1 case) 

156.2 180 

(4 CASES) (1 CASE) 



Showing the averages of the systolic blood-pressure in old typhoids and 
in normal individuals from whom all cases with a history of serious infec- 
tious diseases or alcoholic habits have been excluded. Upper tracing, old 
typhoids; lower tracing, healthy individuals. 



ACUTE INFECTIONS 



129 



'The highest record of blood-pressure among the cases in 
healthy individuals was 180, and that in a woman aged 
sixty years, while among the old typhoids there were 27 
cases in which the pressure was above 180, 10 showing a 
record of 200 or above." Thayer's observation would point 
to a hitherto unsuspected frequency of post-typhoidal 
cardiovascular changes. 

Pneumonia. — There is a marked difference of opinion 
as to the blood-pressure in pneumonia. Kaufmann and 
deBarry 1 believe the pressure is low, and their view is 
shared by Norris, Gibson,* 2 Cowan 3 while others, notably 
Cook and Briggs, Gilbert, Castaigne 4 hold that the disease 
is hypertensive. Gibson says that the pressure is lowest 
at the time of the crisis or immediately after, and rises 
during the next few days. 

During the winter of 1910-11 the author had opportunity 
to observe 20 cases of pneumonia, admitted to the service 
of J. H. Musser in the Presbyterian Hospital, and also five 
cases on his service in the University Hospital. I have 
tabulated these results: 



l 

l 

n 

3 
2 
3 
2 
1 
1 



The lowest pressure was 83 and the highest 212 mm. Hg. 

There are so many factors which must enter into the 
question before an opinion can be given, namely the ques- 
tion of age, condition of heart and bloodvessels, condition 
of kidneys, all of which modify the picture. The day of 
the disease may also play some role, but it must not be for- 
gotten that quotidian variations are also manifest in this 



Between 80 and 90 mm. 


Hg. 


Between 90 and 100 mm. 


Hg 


Between 110 and 120 mm 


Hg 


Between 120 and 130 mm. 


Hg 


Between 130 and 140 mm 


Hg 


Between 140 and 150 mm 


Hg 


Between 160 and 170 mm 


Hg 


Between 180 and 190 mm 


Hg 


Between 210 and 220 mm 


Hg 



1 Berlin, klin. Woch., 1888, p. 557. 

2 Edin. med. Jour., 1910, p. 31. 

3 Practioner, 1904, lxxiii, 218. 

4 Sean, et mem. de. la >Soe. de la Biol 



1899, i, 633. 



130 



ACUTE AND CHRONIC INFECTIONS 



disease and in one case seen in the University Hospital the 
changes were as great as 17 to 20 mm. Hg. 



Fig. 28 

TEMP.o RESP. 



DAY OF 
MONTH 


19 






20 
















21 












•> 2 












23 




106° 140 

105 130 

104 120 

103 110 

102° 100 

101 90 

100° 80 

99° 70 

98° 60 

97° 50 

96° 40 

30 

20 

10 




















































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Blood-pressure above pulse rate. Recovery. Heavy black dots and lines, 
blood-pressure; interrupted open dots, temperature; open continuous dots, 
pulse rate; closed black dots, respiration. 

Hensen 1 has noted a rise of pressure in dyspneic states, 
and Janeway recalls the influence which individual reaction 

1 Archiv. f. kl. Med., 1900, lvii, p. 436. 






ACUTE INFECTIONS 



131 



amount of tissue involved, dyspnea, cyanosis, and many 
other factors exert on the blood-pressure. 



Fig. 29 



SL. PR. « 
Feb. 



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I 


30 wV v' W^ / 


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oU ^_J 


wvv ^ 



Blood-pressure below pulse rate. Death. 



The value of observing the ratio of blood-pressure to 
the pulse rate has been pointed out by Gibson, Gordon, and 
others. It is claimed that when the blood-pressure expressed 
in millimeters of mercury remains above the pulse rate 



132 



ACUTE AND CHRONIC INFECTIONS 



expressed in beats per minute, the case has a favorable 
prognosis. This purely empirical observation has been 
thought so highly of that some claim never to have seen a 
fatal case when the blood-pressure and pulse ratio is thus 
preserved (see Fig. 28), and rarely a favorable outcome when 
the pulse rate rises above the blood-pressure (see Fig. 29). 



Fig. 30 



Fig. 31 





N 


)V 


















DAY OF 

MONTH 


IE 




1-4 












L5 




107° 150 
100° 140 
105° 130 
104° 120 
103° 110 
102 ° 100 
101° 90 
100° 80 
90° 70 
98° 00 
97° 50 
96" 10 
31 
20 














































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100 

107° 150 

100° U0 

105° 130 

101° 120 

103° 110 

102° 100 

101° 90 

100° 80 

99° 70 

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96° 10 

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Blood-pressure above pulse rate. 
Death. 



Blood-pressure above pulse rate. 
Death. 



In 1911 the author 1 reported some work undertaken along 
these lines. 22 cases were studied in the Presbyterian Hos- 
pital, and although it is regret able that blood-pressure 
readings were not made more frequently, some interesting 
facts were learned. 18 of these cases correspond exactly 
with Gibson and Gordon's findings; in 12 there was a 
favorable outcome, the blood-pressure being maintained 

» Therap. Gaz., July 15, 1911. 



ACUTE INFECTIONS 



133 



above the pulse rate, and in 6 the blood-pressure fell below 
the pulse rate and death ensued. 

That the rule of Gibson is, however, too dogmatic and 
inflexible to permit of general acceptance, is shown in Figs. 
30, 31, 32, and 33. 

Fig. 32 



month S 9 | 10 d L2 




'1 \jJ« ^ 


w i f " h y \ 


io., i.o gpf v : ». ( ^ 

»V b r? H a \ 




103 110 | \ I /PjJfV"" ^ V% / \ 




"■" i ,-* \ 


nn° -n 1 1 --*— — — / 


•T^ W X 


9: - -, * ° ^ / \ A* / \ 


, , \iAfcu 1\ L _ !±1 _ 


U JJ \ 







Blood-pressure below pulse rate. Recovery. 



Figs. 30 and 31 are of patients who had a higher blood- 
pressure than pulse rate, but who nevertheless died, and 
Figs. 32 and 33 show a favorable outcome when the pulse 
rate was continuously higher then the blood-pressure. 

While admitting the clinical usefulness of observing 
the blood-pressure, pulse rate ratio, the author does not 
believe that a fatal result always accompanies a blood- 
pressure lower than the pulse rate nor does he regard a 
blood-pressure higher than the pulse rate as a sign of ulti- 
mate recovery. It must not be forgotten that nephritis or 
some conditions raising blood-pressure of itself, may be 



134 



ACUTE AND CHRONIC INFECTIONS 



present in the subject suffering from pneumonia, and hence 
raise that individual pressure far above normal despite 
the influence of the infection. Such individuals are in just 
as much danger from collapse as those with much lower 
pressure, and treatment is as urgently indicated. 



Fig. 33 



DAY OF 1 1 1 

month 23 '24 25 20 27 28 


Sj 


o A A t 1 ft 












101 JU d ^\^*^'' ^ v / ^ ^ 

100' 80 V V ^V- i -V ^ W %\. 






97° 50 * 


96° in „ - «.* / V ^ d V ^ / \ 


%r Xv l~n\^ 1*T V^ 







Blood-pressure below pulse rate. Recovery. 

Stimulation is rarely required when the blood-pressure 
remains above the pulse rate, and this ratio is most useful 
in guiding the administration of drugs, the latter generally 
being necessary when blood-pressure falls below the pulse rate. 

Epidemic Cerebrospinal Meningitis. — Increased intra- 
cranial pressure is always associated with cerebrospinal 
meningitis, and on account of the intricate relationship 
existing between the former and the elevation of blood- 
pressure, which we have learned from Cushing to be a 
fundamental truth, we should expect to find the pressure 



ACUTE INFECTIONS 135 

elevated in meningitis of the epidemic variety. Robinson 1 
has made the most comprehensive study of this question 
which has yet appeared. 

Observations were made in 26 cases of meningitis and 
from these, 336 blood-pressure estimations were charted. 
The effect on blood-pressure of removal of fluid by lumbar 
puncture was studied 38 times in these 26 cases and seven 
times in other conditions. The Stanton instrument with a 
10 cm. arm band was used, and the systolic pressure was 
determined by palpation. 

The tension of the cerebrospinal fluid as measured by a 
manometer w T as as follows: 

Above 500 mm 3 times 

400 to 500 mm 5 times 

300 to 400 mm 4 times 

200 to 300 mm 2 times 

150 to 200 mm 2 times 

The normal pressure being about 120 mm. there is evidence 
in the above table of a constant increase in intracranial 
pressure. There was no constant relation between blood- 
pressure and the heightened intracranial pressure, although 
there was at times an increased blood-pressure, which 
makes meningitis an exception to the rule that "in infectious 
diseases the pressure is lowered." 

As a rule heightened blood-pressure is seen in the early 
acute stage when exacerbations of symptoms occur, late in 
the disease, or when the condition becomes chronic. It is 
higher when the symptoms are severe and low during con- 
valescence. 

Robinson points out " the lack of uniformity in the blood- 
pressure curves, and the great irregularity of the individual 
curves, the highest blood-pressures were encountered in two 
stages of the disease, early, with the severe symptoms of 
onset, and later, with the pre-terminal symptoms, before the 
final failure of the circulation appeared." He finds a rela- 
tionship between the severity of the symptoms and blood- 
pressure, the pressure increasing with increase of symptoms, 

1 Archives Int. Med., 1910, v, p. 482. 



136 ACUTE AND CHRONIC INFECTIONS 

namely, fever, headache, delirium, rigidity of the neck, and 
ocular disturbances. 

The writer derived great assistance recently from the 
sphygmomanometer in a suspected case of meningitis. 
The patient was a negro, who was admitted to the Presby- 
terian Hospital with a diagnosis of typhoid fever. The 
blood-pressure was 110 mm. Hg. and a careful study led ulti- 
mately to the diagnosis of paratyphoid fever. A few days 
after admission, the patient began to show signs of menin- 
gitis, i. e., rigidity of the neck, spasticity of the limbs and 
cerebral symptoms. The blood-pressure, however, did not 
rise, and the lumbar puncture, apart from revealing increased 
pressure of the cerebrospinal fluid, showed nothing to indi- 
cate the presence of a meningitis. Following the puncture, 
the patient improved, and the meningeal symptoms gradually 
disappeared. Future work may show that in low blood- 
pressure we have a means of helping to distinguish meningeal 
irritation from true meningitis. 

The effect on blood-pressure of lumbar puncture is not 
constant, although it is frequently lower after than before, 
and the hypertension which is frequently seen in epidemic 
cerebrospinal meningitis is probably not due to the increased 
intracranial tension. Muscular movements such as those 
accompanying delirium may play a role, or there may be 
reflex stimulation of the blood-pressure raising mechanism of 
the body, by irritation of the cerebral nervous mechanism 
as by pain. Internal hydrocephalus or pyohydrocephalus 
may also be causes of the increased blood-pressure. 

It is interesting to see such an inconstant fall of arterial 
pressure after lumbar puncture, as we know that the punc- 
ture generally brings about a considerable drop in pressure 
(see Lumbar Puncture). 

Diphtheria.- — Rolleston 1 has made most careful observa- 
tions on 179 cases of diphtheria, using the palpatory method 
of determining systolic pressure. His conclusions which are 
affixed to a classic article, containing good bibliography, are : 

1 . In a series of 179" eases of diphtheria, the blood-pressure 

1 Brit. Jour. CM. Dis., 1911, viii, p. 433. 



ACUTE INFECTIONS 137 

was found to be subnormal in 63 patients, or 35.1 per cent., 
the extent and duration of the depression having, as a rule, 
a direct relation to the severity of the faucial attack. 

2. In the great majority, the highest readings are found in 
the first, and the lowest in the second week of disease. The 
normal tension is usually reestablished by the seventh week. 

3. In a large proportion of convalescent cases, either 
the readings in the recumbent and erect positions are the 
same, or the recumbent is higher than the vertical record 
until convalescence was firmly established. 

4. In laryngeal cases, disproportionately high readings 
are obtained, especially when the dyspnea is sufficiently 
severe to require operation. Relief of the obstruction by 
tracheotomy is followed by an immediate and steep fall 
of blood-pressure (20 to 40 mm.). 

5. The blood-pressure shows little tendency to be affected 
by the early serum phenomena, but during the late febrile 
syndrome it may be raised. 

6. Albuminuria is accompanied either by a fall or by 
no change in the blood-pressure, except in cases of uremia 
in which there is hypertension. 

7. In early paralysis, the blood-pressure tends to fall. In 
late paralysis, even when extensive, it is usually not affected. 

8. Sphygmomanometry in diphtheria, as in other acute 
diseases, though of considerable theoretical interest, has little 
practical significance. 

9. Adrenalin therapy in diphtheria may favorably influ- 
ence the other symptoms of suprarenal insufficiency without 
affecting the blood-pressure. 

In the fatal cases, there is little prognostic importance to 
be attached to blood-pressure estimations. In the majority 
of cases the pressure was variable in its manifestations, in 
no cases did death take place unexpectedly, the character- 
istic features of malignant diphtheria indicating a lethal 
outcome before there was any lowering of blood-pressure. 

Anaphylaxis. — The distressing but happily infrequent 
phenomena of "anaphylactic shock," are now supposed to 
be due to spasm of the unstriated muscles of the finer divi- 
sions of the bronchial tree, death being due to strangulation. 



138 ACUTE AND CHRONIC INFECTIONS 

This condition is produced by peripheral action and seems 
to be in no wise of central origin. There is with the phe- 
nomenon of anaphylaxis a rise in blood-pressure and later 
a fall. Atropin brings about relaxation of the over-dis- 
tended lung, and if given before the serum it may prevent 
the fatal lung distension. 1 

Pearce and Eisenbrey 2 have studied the question of 
anaphylactic "shock" in dogs, and describe an abrupt fall 
of blood-pressure, averaging 50 to 70 mm. of mercury. 
Respiration is unaffected apart from disturbances due to 
anemia of the medulla, arising from the low blood-pressure. 
The low blood-pressure and the associated decreased periph- 
eral circulation are accompanied by congestion of the 
veins of the splanchnic area, flooding of the splanchnic 
sea. The authors confirm the findings of Auer and Lewis 
and show conclusively that the low pressure is caused by 
influences on the peripheral nerve endings of the vaso- 
motor mechanism. The ''shock" is accompanied by a 
sudden persistent fall in blood-pressure and by symptoms 
due to cerebral anemia. 

Scarlet Fever. — A study of the systolic pressure in cases 
of scarlet fever shows the pressure to be subnormal in 25 per 
cent, of the cases, the hypotension being in direct relation to 
the severity of the onset of the disease. The highest of 
these low tensions are found in the first week, but there 
is a predominence of the lowest, also in this week, although 
the majority of the lowest readings are obtained in the 
second week. Normal pressure is not attained until the 
fourth week. In convalescence the tension is lower than 
in the acute stages. 

Complications have little effect on blood-pressure. In 
only a small proportion of the cases showing signs of 
renal insufficiency is there a rise in blood-pressure, and 
even in these cases the hypertension was never extreme 
or of long duration. Sphygmomanometry has here, as in 
diphtheria, but little prognostic value. The early fatal 
cases do, it is true, show a marked fall in pressure than 

1 Auer and Lewis, Jour. Amer. Med. Assoc, 1909, liii, p. 458. 

2 Jour. Infec. Diseases, 1910, vii, p. 565. 



ACUTE INFECTIONS 139 

do the fatal cases of diphtheria, but this has little signi- 
ficance. Blood-pressure readings should be made in cases 
of postscarlatinal nephritis, as such may show the extent 
of the renal lesion. This hypertension and the pronounced 
low tensions occasionally encountered, are indications for 
treatment. 

Cholera. — An interesting research on blood-pressure 
during the cholera epidemic in St. Petersburg, (1909-10), 
has been made by Lang. 1 He has found in the algid state, 
a lowering of systolic pressure and a rise in diastolic, this 
being due to a small volume of blood (loss of water) with 
a consequent narrowing of the lumen of the vessels. Salt 
solution in quantities of two liters causes the blood-pressure 
to approach more nearly the normal, on account, probably, 
of restoration of the total volume of liquid in the blood- 
vessels. When too much salt solution is injected (intra- 
venous), that is, when more is administered than fluid lost, 
blood-pressure, both maximal and minimal, rises above 
normal. 

After the algid state, there is a rise of blood-pressure for 
the first few days. 

Federn 2 takes an entirely different view and says, in 
cholera, "the blood-pressure is 140 mm. and perhaps higher, 
as I have seen no patient in the algid state," 

Malaria. — Federn 3 made observations on three cases, and 
finding the pressure so characteristically raised, he con- 
cluded this must be the rule. The pressure is raised only in 
the febrile stage, during the chill and fastigium of fever, and 
drops when sweating begins. 

Norris, 4 on the other hand, finds nothing of importance 
to be derived from blood-pressure observations in malaria. 

Other Infections. — Acute Articular Rheumatism. — Norris 
found no change of consequence, but Potain 5 considered 
it a hypertensive condition. 

1 Deutsch. Arch, fur klin. Med., 1912, cviii, p. 236. 

2 Verhandl. d. Kongresses fur inn. Med., 1904, xxi, p. 582. 3 Loc cit. 

4 Amer. Jour. Med. Sci., 1903, cxxv, p. 880. 

5 La pression arterielle de l'homme a l'etat normal et pathologique, Paris, 
1902. 



140 ACUTE AND CHRONIC INFECTIONS 

Influenza. — Hypotension is the rule in influenza. 

Paratyphoid Fever. — Three cases of paratyphoid fever, 
whose blood contained specific agglutinins for the alpha 
strain, have been under my care lately, and in each there 
was hypotension. 

H. CHRONIC INFECTIONS AND INTOXICATIONS. 

Tuberculosis. — Schnitter 1 has given a concise table of the 
blood-pressure in the various stages of tuberculosis. He 
has divided his cases into the three degrees suggested by 
Turban, namely: 

First Degree. — Diseases of slight severity, affecting at 
most one lobe or two half lobes. 

Second Degree. — Disease of slight severity, more extensive 
than first, but affecting at most two lobes, or severe and 
affecting at most one lobe. 

Third Degree. — All cases of greater extent and severity 
than second. 





Tub. pul. 


Tub. pul. 


Tub. pul. 


Only 




First 


Second 


Third 


afebrile 


Systolic pressure. 


degree. 


degree. 


degree. 


tub. pul. 


60 to 100 mm. Hg. . 


... 35 


35 


62 


26 


100 to 115 mm. Hg. . 


. . 39 


53 


29 


37 


115 to 130 mm. Hg. . 


. . 16 


4 


4.5 


26 


Above 130 mm. Hg. . 


. . 10 


8 


4.5 


11 



It will be seen that the more severe the tuberculosis 
the more often will low pressure be observed and the greater 
will be the hypotension. Of the 100 cases of tuberculosis 
tabulated above, 48 per cent, had marked lowering of pres- 
sure, 37 per cent, a moderatd lowering, in 7 per cent, a 
tension above 130 mm. Hg. and in 8 per cent, the pressure 
was normal. 

Of the febrile and afebrile cases the following table will 
give Schnitter's results: 

Systolic pressure. 

60 to 100 mm. Hg 

100 to 115 mm. Hg 

115 to 130 mm. Hg 

Above 130 mm. Hg 



Febrile. 


Afebrile. 


Per cent. 


Per cent. 


65 


22 


30.5 


48 


1.5 


19 


3 


11 



1 Beitr. z. Klin. d. Tuberkulose, 1912, xxiii, p. 233. 



CHRONIC INFECTIONS AND INTOXICATIONS 141 

In other words, the febrile cases showed lowered blood- 
pressure three times as often as the afebrile subjects. There 
is no constant relation between the pressure and the extent 
of fever, nor is there any ratio between the blood-pressure 
and pulse rate. The blood-pressure is usually higher toward 
evening. Loss or gain of weight does not seem to affect 
the pressure, nor does increase of blood-pressure go hand 
in hand with improvement, and hypotension with a change 
for the worse, although when a case is arrested the blood- 
pressure rises. 

As regards hemorrhages, Xaumann says that of the cases 
with pressure of 100 mm. Hg. or below, 36 per cent, had 
hemoptysis, while persons with higher tension had pul- 
monary hemorrhage in 51 per cent, of the cases, but this 
opinion is probably inaccurate. Acute miliary tuberculosis, 
especially when the meninges are diseased, is associated with 
rise in pressure. 

Peters 1 points out that in his sanitarium, which is 6,000 
feet above sea level, the blood-pressures are higher than 
at sea level or at lower elevations. He does not believe 
that blood-pressure has any causal relation to hemorrhage, 
for if this were the case, more cases of hemoptysis would 
have been met with and, as a matter of fact, but two were 
seen. The degrees of involvement and pressure are not 
related, although there is a rise when improvement sets 
in, which he believes is a reliable prognostic sign. Emerson 
puts the case even more strongly. 2 

Other authorities believe that the more pronounced and 
advanced the tuberculosis, the lower the blood-pressure, and 
vice versa, and he also holds that a low pressure will help to 
differentiate tuberculosis in dubious cases. Prognostically 
it has some significance. The imminence of hemoptysis 
must always be suspected when the blood-pressure rises, 
and he advises measures to combat the hypertension. 

One must conclude that unless there is some associated 
condition like arteriosclerosis or nephritis, there is always 
hypotension. The author does not hold with these enthu- 
siasts, particularly of the French School, that hypotension 
is an early sign of incipient tuberculosis, irrespective of the 

1 Archives Int. Med., 1908, ii, p. 42. z Ibid., 1911, vii, p. 441. 



142 ACUTE AND CHRONIC INFECTIONS 

pulmonary and other clinical findings, although it no doubt 
is a significant sign and should make us heedful that we 
do not rush too rashly into the danger of superficial examina- 
tions and opinions. As to the cause of the hypotension, 
little is known, but it is probable that toxic action on the 
vasomotor centre, the vasomotor nerves, and the heart 
muscle all play a role. Not to be forgotten are the secondary 
effects of the infection, as anemia, loss of weight. 

Apart from the hypotension in its broad aspect, there 
seems to be such divergency of opinion as to its prognostic 
significance and its value as a warning sign of hemoptysis, 
that it is difficult to take a definite stand. 

In children, the blood-pressure is low as it is in adults, 
increasing within one or two hours when the patient is 
transferred to the open air. If kept constantly outdoors 
the pressure becomes normal, and the more advanced the 
case, the lower the pressure indoors, and the greater the 
rise when put in the open air. 1 

Lead Poisoning. — High blood-pressure is a common 
feature of lead poisoning and it has been supposed to be due 
to the arteriosclerosis arising in time from the intoxication. 
The "arteriosclerosis" explanation is hardly correct as it 
has been shown that the vessels in plumbism suffer changes 
in the media (hypertrophy) and that the intima is unaf- 
fected. The changes in the artery have been thought by 
some to be the effect of a direct action of the lead on the 
muscle of the vessel, giving rise to hypertension, and by 
others, to be the secondary manifestations of nervous 
irritation called forth by the lead. 

Without taking up the history and development of our 
present knowledge on the subject 2 it may be stated that 
typical colic is always associated with high blood-pressure. 
Inasmuch as the vascular constriction must not of necessity 
be of maximum degree the blood-pressure rise is a variable 
one. This rise is a gradual one, reaching its acme with 
the explosion of the pain, although a sudden rise occurs 
in some cases. There is no parallelism between the height 
of the pressure and the degree of pain, for Pal quotes 

1 Hoobler, Amer. Jour, of Dis. of Children, 1912, iv, p. 311. 

2 See Pal, "Die Gefasskrisen." 



CHRONIC INFECTIONS AND INTOXICATIONS 143 

cases showing attacks of pain with a pressure of 110 to 
120 mm. Hg. These were, of course, not severe attacks 
but were nevertheless typical in their manifestations. 
After the attack, or rather, during convalescence from 
the intoxication, the pressure gradually falls below normal 
and again rises to the normal. Pal believes that these 
colic-like attacks are due to constriction of the abdominal 
vessels, and proves it by the effect of amyl nitrite which 
aborts an attack. Other effects of the vascular constriction 
are seen in slowing of the pulse and accentuation of the 
second aortic sound. To this must be added cerebral 
symptoms, headache, vertigo, amaurosis, hemianopsia, 
deafness, aphasia, transitory palsies, and even eclampsia. 
Tanqueul has shown that 56 cases of eclampsia occurred in 
72 cases of lead poisoning. Pal mention angina pectoris 
among the rarer symptoms of plumbism, but says he has 
never seen a case. 

The author has had several cases of plumbism lately, and 
among these have been instances of hypotension. It is true, 
however, that the majority of the cases do have increased 
blood-pressure. Irritation of the sympathetic nerves is held 
to be the prime cause of the vascular constriction. 

Gout. — Gout is considered to be a hypertensive disease, 
although no specific work has been done on the subject. 
Haig believes that the high pressure is due to the obstruc- 
tion of the capillaries by uric acid in a colloid form, thereby 
increasing peripheral resistance. 

Alcoholism. — During the first days of a chronic alcoholic 
subject in the hospital (abstinence from liquor) there is a 
relative hypertension which gradually falls in from three 
to eight days to normal. The diastolic pressure is but 
little raised, but the pulse pressure is increased, due to the 
increase of the systolic pressure. 1 

Bichlorid of Mercury Poisoning.— In a case recently under 
my care, for two days the blood-pressure wsls 132-94 and 
129-88 on the respective days. The patient had taken 52 \ 
grains of mercuric chlorid. A decapsulation operation was 
undertaken, but the patient died in a few hours. 

1 Raff, Deutsch. Arch, fur klin. Med., 1913, cxii, p. 209. 



144 ACUTE AND CHRONIC INFECTIONS 



III. MISCELLANEOUS. 

Acute Pulmonary Edema. — The belief is that this obscure 
condition is accompanied by hypertension. Amblard has 
studied the blood-pressure in patients before, during, and 
after the attacks, in several cases. These figures are per- 
haps best studied in tabular form. 

Before, systolic. Before, diastolic. During, systolic. During, diastolic. 

1. 280 mm. Hg. 210 mm. Hg. 222 mm. Hg. 190 mm. Hg. 

2. 270 mm. Hg. 190 mm. Hg. 200 mm. Hg. 160 mm. Hg. 

3. 250 mm. Hg. 180 mm. Hg. 190 mm. Hg. 160 mm. Hg. 

4. 240 mm. Hg. 160 mm. Hg. 155 mm. Hg. 130 mm. Hg. 

During the attack, it is seen that the two pressures fall 
but the maximum pressure becomes relatively lower than 
the minimum. 

After the attack, the systolic pressure gradually rises, 
the diastolic remaining essentially the same, but the former 
does not attain the height it reached before the crisis. 

Amblard interprets these findings as pointing to a func- 
tional insufficiency of the left ventricle as a cause of the 
pulmonary edema, this inefficiency being brought about by a 
raising of the diastolic pressure. The latter, indicates increase 
in peripheral resistance, and in order that there may be the 
normal difference between systolic and diastolic pressure, 
the systolic rises to such a degree that the left ventricle 
becomes tired, the pulse more rapid, and acute pulmonary 
edema is produced with a subsequent fall in systolic pres- 
sure. Precautionary measures directed^ toward preventing 
an attack are described. 

Pneumothorax. — In penetrating wounds of the thorax 
giving rise to hemopneumothorax, there is usually a slow, 
full pulse, similar to that seen in brain injuries, and called 
pressure pulse or Druckpuls (Sauerbruch) . The cause of 
the slowing of the heart with its rise of pressure has been 
held 1 by Sauerbruch to be due to the accumulation of 

1 Sauerbruch, Mitteil. a. d. Grenzgeb., 1904. 



MISCELLANEOUS 145 

carbon dioxide in the blood and to irritation of the vagus. 
What the cause of the latter is, is doubtful, whether reflex 
or mechanical (collapse of the lung) , but Kakowski 1 believes 
that in addition to the direct stimulation of the vasomotor 
centre by carbon dioxid and to the strong muscular con- 
traction, there is a third factor to be seen in reflex stimu- 
lation of the vasoconstrictor nerve through the skin and 
pleura. The latter point he was able to emphasize by 
observing no rise in pressure after cutting the vagi, and 
he believes that the vagi, in pneumothorax, behave like a 
sensory nerve. Sensory nerve fibers have been found by 
Ramstrom to exist in the parietal pleura, 2 but none has 
been found in the visceral pleura. 

Walther 3 has lately made some experiments undertaken 
to elucidate, if possible, the cause of the blood-pressure 
rise. He was not able to confirm the findings of Sauerbruch 
and others, of the role of the vagus in its production, but 
believes it is solely the function of the vasomotor centre. 
The slowing of the pulse is due to irritation of the vagi. 
In studying the effect of increased pressure in a closed 
pneumothorax, there was not a rise in pressure with mod- 
erate pressure, but when a great tension is suddenly pro- 
duced, there is a fall, then a rise, and then a drop. For 
details concerning the physiology of these changes in arterial 
pressure the reader is referred to Walther's original article. 
The study of blood-pressure in artificial pneumothorax 
should be of great importance. 

Respiratory Diseases. — The role that dyspnea plays in 
the elevation of blood-pressure in certain respiratory dis- 
eases can not be wholly neglected. It is true that dyspnea 
appears only on exertion, and that the blood-pressure, 
even when the patient is at rest, is raised. On the other 
hand, subjective dyspnea is but one expression of a defective 
interchange of gas, and one can conceive of lesser grades 
than that required to produce subjective discomfort, 
notably imperfect interchange of gases between the tissues 

1 Pfliiger's Arcliiv, 1910, p. 134. 

2 Mitt. a. d. Grenzgeb., 1906. 

3 Deutsch. Zeitsch. fur Cbirurgie, 1912, cxix, p. 253. 
10 



146 ACUTE AND CHRONIC INFECTIONS 

and the blood without any visual manifestation of the same. 
Just how great a part this plays, one can but surmise, but 
it should not be entirely disregarded. Hensen, indeed, 
believes that the dyspnea is the underlying cause of hyper- 
tension in respiratory disease, it being directly responsible 
for the latter. 

(a) Asthma. — In judging of this disease, one must have 
in mind bronchial asthma as distinguished from cardiac 
asthma, renal asthma or any of the paroxysmal attacks 
of a secondary or reflex nature. There has been found an 
elevation from 100 mm. Hg. to 140 during the attacks 
returning to normal during the periods of remission. These 
elevations may be due to nervous influences and to forced 
expiration, both of which would raise the blood-pressure 
in the absence of dyspnea. 

(b) Chronic Bronchitis and Emphysema. — Janeway and 
others have found hypertension in these conditions, but 
ascribe it to a latent angiosclerosis, rather than to dyspnea 
or any factor inherent in the respiratory disease itself. 

Pleural Effusion and Ascites. — Both of these tend to 
produce hypertension, but pleural effusions have a greater 
effect than peritoneal ecudations. After tapping, the 
pressure falls, there being more of a change with large pleural 
than with large abdominal effusion (see Fig. 34). 

Raynaud's Disease. — Blood-pressure studies in cases of 
Raynaud's disease have as yet not been made in any great 
numbers. The writer has a case under his care, a laborer, 
aged thirty-six years, who has been suffering for six years 
with sudden whitening of his fingers. The blanching in- 
volves either one finger, or all fingers, and the attacks occur 
irregularly, sometimes every day and sometimes not for 
several days. 

When I first saw the man the blood-pressure was 126- 
78 mm. Hg. During an attack the pressure was 154-86 
mm. Hg. and just after the attack it fell to 118-72 mm. Hg. 
Before each attack there was a rise in blood-pressure, though 
this was not as marked as at the first observation. Between 
the attacks there was no constant blood-pressure figure, 
the blood-pressure varying between 118 and 146 mm. Hg. 



MISCELLANEOUS 



147 



(systolic). The diastolic pressure was little affected by 
the attacks. 

Fig. 34 



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Blood-pressure and Insurance. — Much valuable informa- 
tion has been afforded by the study of blood-pressure in 
insurance work. High blood-pressure is the only feature 
which has been given much attention, but it is gratifying 
to note that many of those making examinations are turning 
their attention to hypotension as well. 

Inasmuch as pressures above 150 mm. Hg. generally 
spell nephritis, an insurance examiner should regard such 
pressures with suspicion. A well-known company has 
furnished statistics which show the wisdom of this state- 
ment, for of 365 cases rejected on account of high blood- 
pressure alone (170 mm. Hg.), 136, 35 per cent, later proved 
to be suffering with various serious ailments, any one of 
which would have provided a basis for rejection. The 



148 



ACUTE AND CHRONIC INFECTIONS 



mortality in these cases was 144.51 per cent., only a little 
below that of those cases rejected on account of high blood- 
pressure and one or more other impairment, in whom the 
mortality was 161.9 per cent. 

Some interesting tables are furnished by Fisher. 1 
723 persons were rejected, with an average blood-pressure 
of 171.03 mm. Hg. (Table III). 358 of the 723 rejected 
cases, with an average blood-pressure of 171.73 mm. Hg., 
showed one or more other impairments than the high 
blood-pressure (Table IV). These impairments will be found 
in Table V. 365 cases, the remainder of the 723 rejected, 
showed an average blood-pressure of 170.36 mm. Hg. (Table 
VI). Of the 365 cases (Table VI), no other impairment 
was recorded on the application when received at the home 
office. 



Table I. — Mortality of Accepted Risks with Systolic Blood-pressure of 

140-149 mm. Hg., with an Average of 142.43 mm. Hg. 

All Ages. 



Years. 


Number. 


Expected. 


Actual. 


Per cent. 


1907 


217 


14 


884 


7 


47 


03 


1908 


652 


41 


221 


21 


50 


94 


1909 


953 


42 


088 


12 


28 


51 


1910 


846 


25 


215 


18 


71 


39 


Total 


2,668 


123 


408 


58 


47 


00 



Table II. — Mortality of Accepted Risks with Systolic Blood-pressure of 

150 mm. Hg. and Over; Average 152.58 mm. Hg. 

All Ages. 



Years. 


Number. 


Expected. 


Actual. 


Per cent. 


1907 
1908 
1909 
1910 


87 
210 
163 

65 


6.194 

14.398 

8.432 

2.238 


6 

10 

3 

3 


96.87 

69.45 

35.57 

134.05 


Total 


525 


31.262 22 70.37 



Medical Record, 1911, p. 818, and 1912, p. 1075, 



MISCELLANEOUS 



149 



Table VII shows the impairments which were discovered, 
or which subsequently developed in Table VI. Had it 
not been for the high blood-pressure, almost all of the cases 
would have been approved and the policies issued. 

Table III. — Mortality of Applicants Rejected with Average Systolic Blood- 
pressure of 171.03 mm. Hg. 
All Ages. 



Years. 



Total 



Number. 



723 



Expected. 



Actual. 



33.288 



51 



Per cent. 



1907 


40 


3.193 


10 


313.18 


1908 


120 


8.429 


13 


154.23 


1909 


• 210 


11.095 


16 


144.21 


1910 


225 


8.408 


9 


107.04 


1911 


128 


2.163 


3 


138.69 



153.21 



Table IV. — Mortality of Applicants Rejected with High Blood-pressure 

(average 171.73 mm. Hg.) and One or More Other 

Impairments. 



Number. 


Expected. 


Actual. 


Per cent. 


358 . 16.680 


27 


161.99 



Table V. — Impairments Recorded on Applications at Time of Medical 

Examinations of the 358 Cases Recorded in Table 

No. IV Above. 









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358 



Table VI. — Mortality of Applicants Rejected with High Blood-pressure 
Only. (Average 170.36 mm. Hg.) 



Number. 



Expected. 



Actual. 



Per cent. 



365 



16.608 



24 



144.51 



150 



ACUTE AND CHRONIC INFECTIONS 



Table VII. 



-Impairments Subsequently Discovered or Developed in the 
365 Cases Recorded in Table No. VI Above. 



is 


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The practising physician can well learn a lesson from his 
confrere in the insurance office, and forecasts concerning 
the future health of patients with hypertension should be 
tempered with marked conservatism. 

No one can deny the seriousness of hypertension as far 
as insurance work is concerned. It would be a matter of no 
little importance if statistics w£re collected having hypoten- 
sion as a basis. For instance, in view of the common asso- 
ciation of hypotension with tuberculosis, it would be valuable 
to know what proportion of cases rejected on account of 
low blood-pressure and doubtful physical signs later de- 
veloped tuberculosis, or what relation hypotension bears 
to resistance against disease. With the number of appli- 
cants and the routine estimation of blood-pressure it would 
not be difficult to collect statistics on hypotension which 
would be of the utmost value. 



CHAPTER IX. 
BLOOD-PRESSURE IN NERVOUS DISORDERS. 



I. GENERAL CONSIDERATION OF INCREASED ARTERIAL 

TENSION IN DISEASES OF THE CENTRAL 

NERVOUS SYSTEM. 

Many of the diseases of the brain may be divided into 
broad groups, the first comprising processes causing local 
compression of the brain; second, processes causing general 
compression of the central nervous system. The first 
group, then, would include new growth, abscess, blood clot, 
abnormal collection of fluid in one part of the cerebrospinal 
canal. In the second class of cases are found acute cerebral 
edema arising from traumatism, acute hydrocephalus, 
meningitis, subdural hemorrhage. 

Experimentally the conditions of local and of general com- 
pression have been most thoroughly studied. 1 The effects 
of local compression vary a great deal according as the 
compressing agent in close proximity to or remote from the 
fourth ventricle, and these, from the stand-point of blood- 
pressure estimations, are of variable importance. 

It is not until the intracranial tension approximates the 
blood-pressure that the pressure symptom-complex (dishing) 
is produced (Fig. 35). It was formerly supposed that when 
such a degree of pressure was attained, death ensued, but has 
been shown quite definitely that this is not so, but that 
there occurs a stimulation of the vasomotor centre, which 
occasions a rise of blood-pressure to such a degree that 
the high intracranial tension is overcome. If the brain 
cortex be examined when intracranial tension and blood- 

1 dishing, Amer. Jour. Med. Sci., 1902, cxxiv, p. 375; 1903, cxxv, p. 1017. 



Fig. 3.' 




ARTERIAL TENSION 153 

pressure begin to approximate, the rosy color becomes a 
grayish-yellow hue, and there seems to be little if any 
circulation between the arteries and the veins. As soon as 
the blood-pressure begins to rise, following stimulation 
of the vasomotor centres, the red color returns, the centres 
are again nourished, and respiration, which has ceased, 
recommences. If increase of intracranial pressure be 
carried beyond the new blood-pressure, the latter rises 
again, and by repeating this process the blood-pressure may 
be elevated two or more times its original value. Pressure 
can be carried to 250 mm. Hg. and maintained there for 
some time without any sign of vasomotor fatigue. 

When the intracranial tension is suddenly brought to 
a height exceeding the blood-pressure, instead of gradually, 
as in the foregoing, the vagi are tremendously stimulated, 
causing cardiac arrest for a period exceeding thirty seconds 
at times. If this suddenly increased tension is kept up, 
the heart beats again and the blood-pressure gradually 
ascends to meet the level of intracranial tension. Cushing 
thinks this experiment imitates very closely the phenomena 
seen in clinical conditions. Just how long the reaction can 
be carried on varies a great deal, the more slowly the pressure 
is increased, the longer will the vasomotor centre respond, 
but after a time it weakens, there is dilatation of the vessels 
in the splanchnic area with resultant fall of blood-pressure 
below that of the brain, there is asphyxia of the respiratory 
centre and death ensues with a rapidly beating heart and 
a low blood-pressure. It has been thought that death in 
cases of high intracranial tension, respiration stops before 
the heart, but probably behind the respiratory failure there 
is vasomotor collapse, the vasomotor mechanism having 
become exhausted from maintaining the blood-pressure 
above the intracranial tension. 

To summarize briefly, it may be stated that in a slowly 
forming intracranial condition blood-pressure is not elevated, 
whereas, in acute cerebral compression (extravasation of 
blood), there is always increase of arterial tension. In the 
latter case there is a definite regulating mechanism whose 
mission it is to maintain the blood-pressure above the intra- 



154 BLOOD-PRESSURE IN NERVOUS DISORDERS 

cranial tension, and thus to prevent a bulbar anemia which 
is fatal (respiratory failure). A less important function 
of this vasomotor regulating mechanism is seen in the 
slowing of the pulse, although it does not play any role 
in the total blood-pressure reaction. 

So much for the experimental side. In summing up his 
memorable monograph in Nothnagel's Specielle Pathologie 
und Therapie, 1901, lx, 3, p. 186, Kocher gives the follow- 
ing classification of the stages of compression seen in the 
clinic: 

1. Stage of Compensation. — This corresponds to the stage 
of latent intracranial pressure, which formerly was so 
much talked about but which possesses no "latency" at all, 
as one may at this time find in man signs of pressure such as 
choked disk and in animals escape of liquor cerebri from 
the nose, and increase of venous pressure. The usual signs 
of this stage are insignificant, however, as the escape of 
cerebrospinal fluid and compression of the sinus and veins 
can compensate for the increased tension. There is prac- 
tically no increase in blood-pressure. 

2. Beginning Stage of Manifest Pressure. — If the cerebro- 
spinal fluid has escaped from the skull and if the veins are 
as much compressed as they can be without absolute oc- 
clusion, then the second stage begins. The side channels 
of venous escape being blocked off there results venous stasis 
and a lessening of the blood-flow through the capillaries 
(dy sdiamorrhy sis) . Signs of compression appear together 
with symptoms of irritation of the meninges: headache, 
vertigo, pain in the limbs, unrest, tinnitus aurium, altered 
sensorium with excitement, delirium, jacitation and sleep 
disturbed by dreams. 

3. Height of Manifest Pressure. — The capillaries emptying 
themselves so slowly, there results cerebral anemia. If there 
is local compression, the anemia is localized, but lasting 
and local paralytic signs are observed such as monoplegia, 
hemiplegia, aphasia, hemianopsia, etc., according to the area 
compressed. There is a ready tendency of the anemia to 
invade other portions of the brain cortex, and the effects 
of these may be momentary and intermittent. Provided 



ARTERIAL TENSION 155 

the anemia does not encroach on the medulla, there is no 
immediate fatal outcome, but when the latter is invaded, 
death follows through bulbar anemia. The reason that death 
does not result earlier is on account of Cushing's blood- 
pressure reaction consisting of excitation of the vasomotor 
centre with rise in blood-pressure, strong enough to over- 
come the intracranial tension, and then to drive blood 
again through the capillaries. This anemia is intermittent, 
as a matter of course, and there is always a balancing with 
adiamorrhysis and endiamorrhysis on either end. Respira- 
tion is altered, so that in the stage of anemia of the centre, 
it stops, and in the stage of blood flow, it begins. During 
normal circulation the vasomotor centre is relatively quiet 
but is put into activity immediately when there is anemia. 
The vagus is stimulated to a great degree by the dysdia- 
morrhysis. 

4. Stage of Paralysis. — If there follows still more pressure 
in the vessels, the blood-pressure is able to overcome it 
only in systole, while in diastole the capillaries remain 
empty. Now the change which was rung between adia- 
morrhysis and endiamorrhysis in the third stage is played 
between adiamorrhysis and dysdiamorrhysis and symptoms 
of general cerebral involvement follow: tremor, nystagmus, 
anisocoria, arrhythmia, irregular respiration, and finally 
dilated pupils, intermittent, snoring respiration and rapid, 
running pulse with low blood-pressure. 

The reader is referred to a series of cases reported by 
Cushing 1 which exemplifies most beautifully Kocher's 
classification. Cushing emphasizes the advantage of blood- 
pressure estimation in case of intracranial injury. 

A point which Cushing presses and one to which most 
clinicians will most heartily subscribe, concerns treatment 
of cases of intracranial hemorrhage with a high, bounding 
pulse. His words are indeed worthy of literal quotation. 
"The therapeutic measure generally advocated in cases of 
intracranial hemorrhage with high, bounding pulse is a 
purely symptomatic one, namely, to 'bleed' the patient 

1 Amer. Jour. Med. Sci., 1903, cxxv, p. 1017. 



156 BLOOD-PRESSURE IN NERVOUS DISORDERS 

in order to lower blood-pressure, the idea being, that the 
persistent high tension is the cause rather than the result 
of the hemorrhage. If the interpretation of this experimental 
work is not at fault, such an abstraction of blood with the 
idea of lowering arterial tension would be absolutely contra- 
indicated, since the high blood-pressure is only an indication 
of Nature's effort to overcome the degree of intracranial 
pressure brought about by the foreign body in order to 
ward off an anemic condition of the bulbar centres. Of 
course the tension of the foreign body in this case, com- 
municating as it does with a ruptured artery, is equal to 
that of the arterial tension, and were it not for its remoteness 
ordinarily, from the medulla, death would almost immedi- 
ately ensue, just as it does when a hemorrhage takes place 
in the neighborhood of the medulla or reaches the fourth 
ventricle though ruptured into one of the lateral ventricular 
cavities. 

"In the course of many of the experiments on compres- 
sion the effects of blood-letting (the skull still being intact) 
were tried during the various stages of compression. At 
no time could any beneficial influences be seen, and if 
blood was withdrawn from the general circulation at a 
time when there had been a marked rise in general arterial 
tension to overcome cerebral anemia, and in amounts 
sufficient to lower this arterial tension, the results were 
almost always diastrous unless a certain amount of reserve 
power remained in the vasomotor centre which could make 
return the arterial tension to its former level. I would not 
mean to deny that symptomatic improvement ever follows 
blood-letting in cases of apoplexy in which the symptoms 
have not called forth pronounced symptoms referable to the 
vital bulbar centres, but when such is the case, anything 
which tends to lower arterial tension without an associated 
opening in the skull to correspondingly lower intracranial 
tension, is hazardous to say the least." 



BLOOD-PRESSURE OF LUMBAR PUNCTURE 157 



n. EFFECT ON BLOOD-PRESSURE OF LUMBAR 
PUNCTURE. 

In many pathological states of the central nervous system, 
especially of the brain, tumors, cerebral hemorrhagic men- 
ingitis, cerebral and cerebrospinal meningitis, both serous 
and purulent, there is in addition to the increased pressure 
of the cerebrospinal fluid, increased arterial pressure. If 
the cerebrospinal fluid is allowed to escape until its pressure 
reaches normal, the arterial pressure will fall likewise to 
normal or below normal, depending on the amount of liquid 
withdrawn. The pulse, which has been 40 to 50, becomes 
more rapid after the puncture, reaching normal or slightly 
exceeding it. 

The arterial pressure remains lowered after lumbar 
puncture, the length of time depending on just how rapidly 
the cerebrospinal fluid reaccumulates. This is particularly 
well seen in cases of cerebrospinal meningitis, where it 
may be shown in the same individual that arterial pressure 
rises every time the cerebrospinal fluid accumulates to 
such a degree that its pressure is raised. When the disease 
progresses favorably and the cerebrospinal pressure dimin- 
ishes, arterial pressure becomes again normal. 1 

Lafite-Dupont and Maupetit 2 found that raising a pressure 
in the labyrinth raised the arterial pressure, and when the 
pressure was raised in the cerebrospinal canal, it was again 
raised. Removal of fluid lessened pressure. In man lumbar 
puncture can cause a drop of arterial pressure from 40 to 80 
mm. Hg., this drop lasting several days. 

The question of blood-pressure in lumbar puncture has 
been most carefully studied. The effect of pain, mental dis- 
turbances and muscular contractions have been noted, and 
these are of themselves interesting, as showing that the 
skin puncture is followed in every case by a rise in pressure 
which varies with the amount of pain resulting from the 

1 Parisot, Compt. Rend. Soc. de Biol., 1909, p. 939; cf. section on Epi- 
demic Cerebrospinal Meningitis. 

2 Compt. Rend- Soc. de Biol., 1905, p. 677. 



158 BLOOD-PRESSURE IN NERVOUS DISORDERS 

manoeuvre, and with the degree of consciousness of the 
patient. A greater and a more marked rise is associated 
with the puncture of the dura, which rise is just as marked 
if the patient is unconscious as when he is fully alive to 
his surroundings. Puncture in the dura in a completely 
anesthetized dog exhibits the same phenomena, thus disprov- 
ing any view that the alteration is due to pain or disturbance 
of the higher centres. The effect is probably vasomotor and 
indicates a definite influence on the medullary centres. 

Withdrawal of the spinal fluid is followed by an immediate 
fall of pressure, but there is an almost immediate rise so 
that for at least twenty minutes after the operation, the 
pressure is higher than normal. 

HI. CHEYNE-STOKES RESPIRATION AND BLOOD- 
PRESSURE. 

Pollock 1 has confirmed the findings of Cushing and of 
Eyster in 15 cases of Cheyne-Stokes respiration arising 

Fig. 36 




^^''■'•'''•''''^■tt 



High blood-pressure during apnea; infarct of lung. 

from various causes, including cerebral hemorrhage, cerebral 
and general arteriosclerosis, myocarditis, decompensated 



Arch. Int. Med., 1912, ix, p. 406. 



INSANITY AND OTHER CONDITIONS 



159 



heart lesions, pneumonia, infarct of the lungs, and nephritis. 
Two curves are reproduced from his article, showing the 
high blood-pressure during apnea in infarct of the lung (Fig. 
36), and low pressure, during apnea in a case of cerebral 

hemorrhage (Fig. 37). 



Fig. 37 




. 






till,, „,,„# ' mm 

.,'■■■. fei^Y 



Low pressure during apnea; cerebral hemorrhage. 

It may be definitely stated that in Cheyne-Stokes respira- 
tion due to increased intracranial tension, the blood-pressure 
begins to rise slightly before respiration commences, becom- 
ing highest at the height of rapid breathing, and then 
falling to reach its lowest point during apnea. In cases in 
which there is no increased intracranial tension, the pressure 
begins to fall when respiration commences, rising and becom- 
ing highest during apnea. 



IV. INSANITY AND OTHER CONDITIONS. 

Melancholia. 1 — In cases of acute melancholia the average 
pressure is 150 mm. Hg., the range being between 140 and 
160. Usually the more profound the depression, the higher 



1 Craig, Lancet, 1S98, i, p. 1742. 



160 BLOOD-PRESSURE IN NERVOUS DISORDERS 

the pressure, and the latter seems to be higher in women 
than in men. A curious coincidence was the mental improve- 
ment as the day went on, associated with lowering of 
blood-pressure. Craig publishes two interesting tables, 
the one illustrating the former observation, and the second 
showing blood-pressure before and after treatment; im- 
provement and even recovery being noted in every case 
in which there was a fall of blood-pressure. It may be 
stated that there was lowered blood-pressure in every case 
which improved or recovered. Others insist that the 
pressure is always elevated in melancholia, but Craig is 
not so emphatic, as in depression with motor restlessness, 
the so-called agitated melancholia, the blood-pressure 
readings are somewhat varied, although when restlessness 
becomes extreme the blood-pressure is sometimes low. 

Alexander 1 divides melancholia into four varieties; sim- 
ple melancholia, acute passive melancholia, acute demon- 
strative melancholia, and chronic melancholia. There is 
marked elevation of the blood-pressure in the simple form 
of the malady but in the acute passive type it is always 
high (155 mm. Hg., Hill and Barnard). The course of the 
blood-pressure is irregular in agitated melancholia, while 
in chronic melancholia the blood-pressure is generally low, 
an elevation occurring when the mental symptoms became 
more acute. 

Regarding the role blood-pressure plays in insanity, 
Craig favors the view that the high pressure is the cause 
of the mental depression, and Alexander, that the high 
blood-pressure is due to toxemia arising from the retention 
of waste products of tissue metabolism. The view of Craig 
does not make a strong appeal, as mental depression occurs 
with hypotension and many cases of hypertension are seen 
with no sign of melancholia. Surely hypertension alone 
cannot explain the mental state. 

Acute Mania. — A constant lowered tension seems to be 
the rule in acute mania, the average being 105 to 110 mm. 
Hg. (Craig), Pilcz has also found lowered pressure, but 

' Lancet, 1902, ii, p. IS. 






INSANITY AND OTHER CONDITIONS 1G1 

gives the very good advice, to bear in mind the possible 
association of a chronic nephritis, which Avill upset all 
calculations. Alexander studied 16 cases of acute mania, in 
which the readings obtained were invariably above normal. 
Alexander noted improvement with fall of pressure and 
Craig with rise to normal. Baths of seven and eight hours' 
duration seemed to have had in Craig's hands a most 
soothing effect on the patient and also caused the pressure 
to rise from 105 to 120 and 130. Before the bath the patient 
was. very excited and after the bath she was quiet and 
reasonable. Such divergent views prevent one from having 
definite ideas on the subject. 

General Paresis. — The arterial pressure (Gartner) is 
at the lowest normal figures in this disease but as the disease 
progresses, it falls very low (50 mm. Hg., Pilcz). With 
remissions of good health, the pressure rises. A sudden 
fall is common just before death and Pilcz claims 
in this sign a very serious and reliable omen of impending 
dissolution. Nephritis of course, vitiates these findings. 
Craig has had limited experience with unsatisfactory 
material, but believes the pressure is high at first, but later, 
is low and suggests that cholin arising from the disinte- 
grating nerve tissue may be the cause of this depression of 
tension. 

In connection with the subject of general paresis it might 
be added that in treating this condition by means of sal- 
varsan, McKinniss 1 found no rise in pressure even when 
195 c.c. saline salvarsan solution was injected. 

Circular Insanity (Folie circulaire). — Judging from ob- 
servation on other types of mental disease it seems more 
than probable that the blood-pressure will vary with the 
mental condition; that is, that it will be raised when the 
person is depressed, and lowered when the subject is excited, 
but that during the period of health it will remain normal. 

In cases of stupor, the reading is higher than in melan- 
cholia, but when the stupor is secondary to mania the 
blood-pressure is low, owing to the exhaustion. 

1 Medical Record, 1912, lxxxii, p. 100. 
11 



162 BLOOD-PRESSURE IN NERVOUS DISORDERS 

It has been pointed out that suicides are common about 
6 a.m., while toward evening the misery is less or has dis- 
appeared and the patient employs or amuses himself, and it 
is hinted that these mental states may follow the physiologi- 
cal decline of pressure which takes place toward evening. 
On the other hand, the maniac is at his best in the morning, 
and the excitement becomes worse about 4 p.m. 

Myasthenia Gravis. — The pressure was found to be what 
Steinert 1 calls the lowermost limit of normal (100 to 120 mm. 
Hg. R. R.). 

Neurasthenia.— There being divergent views regarding 
the type of case one should place under the diagnosis of 
neurasthenia, it is difficult to interpret the blood-pressure 
readings with any degree of satisfaction. The more one 
reads of neurasthenia and the more so-called instances 
of this condition one sees, the less certainty is felt in the 
correctness of this diagnosis. 

Stursberg 2 and Stursberg and Schmidt 3 have studied 
the effect of exercise on blood-pressure in neurasthenic 
states. In 1907, Stursberg wrote that neurasthenic indi- 
viduals showed the same qualitative differences in blood- 
pressure after exercise that normal individuals exhibit, 
but that there was an increase in the dynamics of the 
heart. During rest, the blood-pressure and pulse-pressure 
were higher than in healthy subjects. In their later paper, 
Stursberg and Schmidt arrive at practically the same 
conclusion. 

Their statement that blood-pressure is raised in neuras- 
thenic patients, is open to some criticism, as the medical 
profession, especially neurologists, are far from being of 
one opinion regarding the diagnosis of neurasthenia. 

Epilepsy. — During the time of an epileptic seizure, the 
pressure rises to a great height, and remains high during 
the paroxysm, falling below normal when the attack has 
subsided. This postepileptic depression remains for many 
hours (eight, ten, twenty-four) following a convulsion. 

1 Deutsch. Arch, fur klin. Med., 1903, lxxviii, p. 346. 

2 Archiv fur klin. Med., 1907, xc, p. 548. 

3 Munch, med. Woch., 1913, p. 174. 



INSANITY AND OTHER CONDITIONS 1G3 

When the seizures are rapidly repeated, the arterial tension 
thereafter remains low for days. The explanation for the 
great rise in pressure is the same as for violent muscular 
exertion. 

The differential diagnosis between epilepsy and eclampsia 
by means of the sphygmomanometer will be described on 
page 168. The same general rule guides us in distinguish- 
ing between epilepsy and uremia, namely, that in the former 
the blood-pressure returns to normal after the attack, while 
in the latter it remains high throughout the convulsion 
and the coma. 

Tabes Dorsalis. — As far as blood-pressure determinations 
in disease of the spinal cord are concerned, observations 
seem to be limited to tabes dorsalis. 

It is the belief that the crises of tabes are associated 
with increase of blood-pressure, but that this is not the 
invariable rule, is shown by Pal 1 in two cases. The first 
had a drop in pressure from 125 mm. (Gartner) to 80 mm., 
and the second, from 155 to 110. Pal believes that the 
posterior horns of the spinal cord have vasodilator fibres 
(Strickler), which are irritated in the tabetic process. It 
is true that since tabes is entirely a disease of the posterior 
roots and if irritation caused vasodilatation, low blood-pres- 
sure should be the rule, which it is not, by any means. 
This is explained by supposing vasodilator fibres and vaso- 
constrictor fibres, and, depending on which is the nerve 
irritated, there is a fall or rise of blood-pressure. 

The subject of blood-pressure in tabes is fully described 
in Pal's book, "Gefasskrisen," 1905, in which work an 
attempt is made to explain the critical pain on sudden 
arterial convulsion. The blood-pressure rises pari passu 
with the dimension of the crisis, provided there is no asso- 
ciated cardiac weakness. The amount of pressure is variable 
but it may rise 50 per cent, of the original tension, attaining 
often a percentage of 150 and even more. In one case 
reported the blood-pressure rose from 90 mm. to 200 mm. 

Although tabetics are commonly afflicted with arterio- 

1 Wien. med. Woch., 1904, p. 2. 



164 BLOOD-PRESSURE IN NERVOUS DISORDERS 

sclerosis, the blood-pressure in the interim between crises, 
is not raised. Just before the crisis a rise in pressure may 
be observed, and the crisis is discharged coincidently with 
a high pressure. Therapeutically this has been substan- 
tiated by giving amyl nitrite, which induces an immediate 
cessation of pain. Sodium nitrite had the same effect 
in milder cases. With the onset of menstruation, especially 
when the hemorrhage is severe, the crises are inhibited. 
All these facts, and many more, Pal uses to develop his 
theory that the lancinating pains are produced by local 
arterial spasm. 



CHAPTER X. 
BLOOD-PRESSURE IN OBSTETRICS. 

Pregnancy. — Throughout pregnancy blood-pressure re- 
mains normal. When labor is instituted, the pressure 
rises, and this rise in pressure is in the form of waves cor- 
responding to the periods of uterine contraction. In the 
first labor pains the pressure may rise to 210 to 220 mm. 
Hg., 1 returning to normal during the remissions. Later in 
the labor, pressures of 230 to 240 are seen, but in the last 
stages of labor there is but little fall of pressure, the greatest 
being drops of 20 to 30 mm., never returning to normal. 
When the child is born, pressure falls suddenly and com- 
pletely, and remains normal from there on. When labor has 
been particularly difficult, with considerable hemorrhage, 
the pressure after delivery may be lower than normal but 
this rises, so that on the following day it is again at its 
normal level. Vaquez has never observed the progressive 
return of which some authors write. He emphasizes most 
strenuously, that there is not, either antepartum or post- 
partum, a physiological hypertension, and that only during 
labor itself, is the pressure elevated as the necessary result 
of effort, and he insists that any hypertension before or 
after labor is an index of a pathological state. 

Fig. 38 shows the effect on blood-pressure of some of 
the stages of pregnancy. 2 

With the first pains there is a difference of 10 mm., the 
highest blood-pressure occurring simultaneously with the 
maximum of the contraction. When the latter becomes 
stronger the differences are greater, but there is a return to 

1 Potain and Gartner's instrument, Vaquez. Bull, cle la Soc. d'Obstet. 
de Paris, 1906, ix, p. 30. 

2 Monatseh. fur Geburtshilfe und Gynekologic, 1901, xiv, p. 370. 



166 



BLOOD-PRESSURE IN OBSTETRICS 



normal in the remissions. Immediately after the rupture of 
the membranes there is a drop in pressure 10 mm. below the 
original, more when there is hydramnios. When the pain 
becomes more frequent, and relaxation of the uterus is not 
complete the pressure does not fall to normal between the 
attacks, but rises from pain to pain. Whereas the difference 
in pressure has been 90 mm., when the time for expulsion of 
the infant is at hand it is but 20 mm. The highest blood- 

Fig. 38 



200 
190 
180 
170 
160 
150 
140 
130 
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Schematic representation of blood-pressure during labor: A, pain; B, 
pause; C, rupture of membranes; D, immediately thereafter; E, severest 
pain, appearance of head; F, escape of head; G, immediately after the birth; 
H, uterus firm; J, uterus soft; K, immediately after delivery of placenta. 



pressure is attained at the birth of the head, usually 60 to 
100 mm. above the original pressure. After the birth of the 
child, pressure falls again, 10 to 20 mm. below the original 
level, rises again for one-half minute, and then falls again. 
After this there are variations observed, corresponding to 
the uterine contractions; the stronger the contractions, the 
lower the pressure, the differences being 5 to 20 mm. Hg. 
Hemorrhage has little effect on the pressure, but delivery of 
the placenta causes a fall below the original level. 



ECLAMPSIA 167 

Eclampsia. — The first important work on this subject 
was done by Vaquez and Nobecourt, 1 and their observations 
have not been seriously refuted. They showed at that time 
that hypertension is a premonitory sign of eclampsia. Albu- 
minuria seemed to cause no serious concern so long as the 
pressure remained at the normal level, 130 to 140 (Potain), 
and the}' held that the prognostic sign of the greatest 
importance is the hypertension and not the urinary findings. 
Vaquez 2 has again entered the field, and his results today 
are the same as those of nine years ago, namely, every 
woman, who, in the course of pregnancy or after delivery, 
exhibits increased arterial tension, is in danger of eclampsia, 
whether the urine contains albumin or not. During eclamp- 
sia, persistence of hypertension indicates return of a crisis 
even if other signs are reassuring. Even when eclampsia 
appears to be well controlled cure can only be stated as 
having been accomplished when the arterial pressure returns 
to normal. 

High blood-pressure above 150 mm. is always a warning 
sign, and one should be on his guard against eclampsia. 3 

In a study of 145 pregnant women, repeated blood-pressure 
estimations (1136 readings) disclosed a variable blood-pres- 
sure in health between 90 and 132, the average being 118 
mm. Hg. (Stanton — wide cuff) (Bailey). Bailey 4 agrees 
with Janeway, that a blood-pressure of 160 mm. Hg., does 
not exist in normal pregnancy. I believe 160 mm. Hg. 
is too high a limit, and prefer to view with suspicion 
any blood-pressure that persistently exceeds 140 mm. Hg., 
by the auscultatory method. This statement must not be 
misinterpreted. Sudden rises in blood-pressure from 
excitement, exertion, change of posture, digestion and the 
variations which we know occur in the pregnant as well 
as in the normal woman, are of course excluded, as they 
do not give rise to persistent hypertension. Vaquez's 
warning should sound in every ear, that "every woman, 

1 Soc. Med. des hop., January 9, 1897. 

2 Bull, de la Soc. d'Obstet. de Paris, 1906, ix, p. 34. 

3 Haussling, Jour. Med. Soc. of New Jersey, 1912, p. 242. 

4 Bailey, Surg., Gyn., and Obst., 1911, xiii, p. 505. 



168 BLOOD-PHESSURE in obstetrics 

who in the course of pregnancy, or after delivery, exhibits 
increased arterial tension, is in danger of eclampsia. " Bailey 
remarks, "while it is generally known that cases of eclampsia, 
at the time of the convulsion usually have high blood- 
pressure, still convulsions occur when the pressure is as 
low as 155." This 155 mm. Hg. is evidently too high a 
limit and a safer standard would appear to be 140 mm. Hg., 
although Bailey gives 150 mm. Hg. The latter made his 
readings by the palpatory method, which would make 
the pressure about 160 mm., when estimating by the auscul- 
tatory method. 

Eclampsia and Uremia. — The close resemblance between 
the symptomatology of eclampsia and that of uremia has 
led to the erroneous belief that eclampsia is always a con- 
dition secondary to renal change. This is incorrect, as 
postmortem records of cases show. One will find true 
eclampsia cases with albuminuria, but with no demonstrable 
renal change, and others where there was no antemortem 
or postmortem evidence of nephritis. Chirie 1 reports a 
puzzling case of eclampsia who died finally of uremia, but 
in which the two conditions were definitely distinguishable. 

Eclampsia and Epilepsy. — Chirie 2 also reports a case where 
there was a nice point in diagnosis between eclampsia and 
epilepsy. The patient was a girl, aged seventeen and a 
half years, a primipara, in labor, who had had five con- 
vulsions. After admission, four more crises were noted. 
The differential diagnosis was based on answers obtained 
from the mother as to the girl's childhood, but especially 
on the blood-pressure, which remained normal, before and 
after the birth of the baby. In epilepsy, the pressure is 
high during the attack, but falls thereafter to normal or 
subnormal, whereas in eclampsia, hypertension is a con- 
stant feature. 

Lactation. — After the birth of the child the blood-pressure 
generally falls to about 110 mm., but rises slowly and 
reaches its height the third or fourth day after delivery, when 
the milk appears. The pressure then is about 125 to 130 

1 Bull, de la Soc. d'Obstct. de Paris, 1907, x, p. 80. 

2 Ibid., p. 82. 



LACTATION 169 

mm. Hg. When lactation is established, the pressure falls 
again and approximates that observed before the milk was 
secreted. It will be thus seen that although a persistent 
postpartum hypertension is a sign of disease, yet, neverthe- 
less, there is a temporary rise of blood-pressure which is 
purely physiological and which returns to the antepartum 
level when milk is seen. It seems preferable to speak of 
this postpartum hypertension as a relative or functional 
hypertension. 



CHAPTER XT. 
BLOOD-PRESSURE IN SURGERY. 

Importance of Blood-pressure Records in Surgery. — The 

wide use of the sphygmomanometer among surgeons is a suf- 
ficient testimonial of its value during operative procedures. 
As a means of estimating shock there is no means equivalent 
to the blood-pressure instrument and all investigators are 
agreed that a drop in pressure is the best index to the 
beginning of the dreaded surgical complication. During 
every operation a chart should be kept on which should be 
recorded, every five or ten minutes, the pulse and the respira- 
tion, and every ten minutes the blood-pressure. Bloodgood 1 
has described the details of a method whereby the cooper- 
ation of the surgeon, anesthetist and the chart keeper can 
best be obtained. 

Experimental studies and practical results have shown 
that changes in blood-pressure are a better index to the 
extent of the trauma of the operation than are the pulse 
and respiration. Blood-pressure gives warning of shock 
before changes are observed in the pulse and respiration, 
and by heeding this warning, proper treatment may be 
instituted in time. 

Effect of Anesthetics on Blood-pressure. — Ether. — A 
committee appointed by the Royal Medical and Surgical 
Society, in 1864, to investigate the effect of ether on blood- 
pressure reached the conclusion that ether was without 
any noteworthy effect on blood-pressure. Since then quite 
an opposite opinion has been obtained. Kemp 2 found in 
animals that ether raised blood-pressure, even when anes- 
thesia is but slight, and that when deep anesthesia is ob- 

1 Progressive Medicine, December, 1912, p. 221. 

2 New York Med. Jour., November, 



EFFECT OF ANESTHETICS ON BLOOD-PRESSURE 171 

tained, there is again a rise. Cook and Briggs report a 
rise which they believe is due to the irritating effects of the 
vapor on the mucous membrane of the air passages. A 
second rise is seen in the second stage, probably due to 
muscular effort and the general excitement. They experi- 

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Forcible stretching of left sciatic nerve for sciatica. (Cook and Briggs.) 



mented on themselves and found that when there was no 
general excitement, there was but little change in blood- 
pressure. When anesthesia is deep there is a slight fall 
which is more pronounced if there is sweating, but never 
very low unless there is some degree of shock; when the 



172 



BLOOD-PRESSURE IN SURGERY 



subject begins to "come out" of ether there is generally a 
rise in pressure. The initial rise in blood-pressure is well 
shown in Fig. 39 reproduced from Cook and Briggs' article. 

Chloroform. — All observers are agreed that there is a fall 
in pressure with chloroform, this being due to an effect upon 
the heart and not to an effect upon the vasomotor centre. 
Chloroform stimulates rather than depresses this centre, for 
injection of the drug into the cerebral arteries causes a rise 
in pressure which is still present when respiration ceases. 

Cook and Briggs find that the action of chloroform is 
depressed from the start except in labor, which fact they 
explain as being due to the high blood-pressure occurring 
during labor. 

Fig. 40 





2 S 

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200 
100 
180 
170 
100 
150 
110 
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Anesthesia with nitrous oxid and ether. (Cook and Briggs.) 

Nitrous Oxid. — There is a rise in pressure with nitrous oxid 
which is directly comparable to the changes seen in asphyxia 
(Fig. 40). There is no cardiac depression, however, until 
respiration has become very much interfered with. When 
the respiratory embarrassment takes place there is a fall 
in pressure which is due to impeded pulmonary circulation. 
When used preparatory to ether, there is a rise in pressure 
similar to that seen when ether alone is used, but the later 
secondary rise in tension is almost completely eliminated, 



NITROUS OXID AND OXYGEN 173 

the patient passing from primary to deep anesthesia very 
quickly, thereby saving five to ten minutes of exhaustive 
struggling which would give rise to hypertension. 

Since the introduction of the use of light nitrous oxid 
anesthesia (analgesia) into dentistry, it might be well 
to study its effect on blood-pressure, and this the writer 
has done in a very few instances, but without significant 
result. 

A. C. E. Mixture. — The effects of this mixture are very 
similar to those of chloroform. 

Cocain. — In abdominal operations performed under cocain 
there is not so much alteration in the blood-pressure as is 
seen in operations under general anesthesia. Momentary 
pain or fear causes an irregular rise of blood-pressure. 
Cushing claims that spinal injections of cocain may induce 
hypotension through paralysis of the nerve fibres governing 
the splanchnic circulation. 

Spinal Anesthesia. — Cases of high spinal anesthesia exhibit, 
before the operation, very high blood-pressures, due to men- 
tal anxiety. The lumbar puncture itself (see Lumbar Punc- 
ture), causes a rise, then a "preliminary fall," followed by 
the "main fall" which is more marked (paralysis of the 
thorax), and this in turn by a rise to the original pressure, 
as the paralysis subsides. The "preliminary fall" is due to 
three causes, flaccid paralysis of the abdominal and skeletal 
muscles; subsidence of the disturbance, caused by the 
lumbar puncture; and onset of mental calm. In "low anes- 
thesia" the "main fall" is missing but the "preliminary fall" 
persists. 1 

Nitrous Oxid and Oxygen. — The method of Crile with 
nitrous oxid and oxygen is held by surgeons to be by far 
the safest method yet devised, especially when combined 
with infiltrations of novocain. When anesthesia is begun 
the blood-pressure rises from 5 to 15 mm. Hg. and even 
higher, if there is any struggling or cyanosis. The more 
quiet the patient and the less the cyanosis, the less the blood- 
pressure rises. After the first fifteen to twenty minutes, 

1 Gray and Parsons, Quart, Jour. Med., 1912, v, p. 339, 



174 BLOOD-PRESSURE IN SURGERY 

if the patient is quiet, the anesthetic well taken, and there 
is no cyanosis, the pressure falls slightly, 5 to 15 mm. Hg. 
(Blooclgood). 

Blood-pressure During Surgical Operations. — It seems 
to make little difference as far as the effects of cutting on 
blood-pressure are concerned, whether the patient is anes- 
thetized or not. All incisions irritate the nerve fibers and 
cause reflex vasoconstriction. If pushed beyond a certain 
point operative procedures may have the same effect as if 
the patient were not anesthetized; that is, there will be a 
fall in blood-pressure. This fall in pressure (shock) may be 
transient or permanent, but in either case it is a most 
serious sign, the transient hypotension marking the incep- 
tion for shock and the permanent hypotension indicating 
that shock is well established. Of this we shall speak more 
fully when shock is discussed. 

Operations on the Head and Neck. — There is no change in 
blood-pressure until the dura is reached, when irritation 
of this membrane causes a fall with considerable regularity. 
Elevation of the temporosphenoidal lobe produced a marked 
rise in the blood-pressure (Crile). Hemorrhage occuring 
from the meningeal artery, which was controlled by pack- 
ing, caused a fall, and the latter was probably the combined 
effect of hemorrhage, irritation of the dura, water and the 
pressure of the brain. The amount of shock seems to be 
proportional to the amount of handling the brain receives 
and also the amount of hemorrhage and the duration of the 
operation. 

In operations on the neck there is no distinct relation 
between the kind of operation and the condition of blood- 
pressure, provided there is no asphyxia, in which case, 
there is a rise in pressure. When the vagus had to be divided 
there was no effect on the blood-pressure provided the 
nerve was cut quickly (Crile). 

Operation on the Thorax. — Excision of the breast for 
carcinoma in middle-aged subjects was attended by only 
moderate changes. In extensive operations on the axilla 
there was an irregular decline. The opening of an empyema 
with discharge of pus caused rapid fall in blood-pressure 
(Crile). 



GENITO-URINARY OPERATIONS 



175 



Abdominal Operations. — The chart reproduced from Cook 
and Briggs shows the effect of opening the abdominal 
cavity, there being a rise in pressure, when the peritoneal 
cavity was opened, above the initial rise of blood-pressure 
and above the rise produced by incising the skin. 

































Fig 




41 




































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MM HC 

190 
180 

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150 

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130 
120 

110 
100 
90 
80 
70 
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PULSE 

110 
130 
120 

110 

100 
90 
80 
70 
60 
50 

to 

30 
20 
10 
















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Laparotomy (appendectomy). (Cook and Briggs.) 



The amount of handling and manipulation which the 
viscera receive directs the blood-pressure curve, there 
being a fall when much traumatism is inflicted. Packing 
the abdominal cavity with gauze or flushing out the cavity 
causes a decided decline. In ordinary simple appendectomy, 
but little change is seen, but severer operations such as 
excision of gangrenous bowel in strangulated hernia pro- 
duced lowered pressure. 

Genito-urinary Operations. — During operations for re- 
section of the ovaries, the removal of ovarian tumors, 
excision of the tube for pyosalpinx, myomectomy, hyster- 
ectomy, both abdominal and vaginal, dilating and curet- 



176 



BLOOD-PRESSURE IN SURGERY 



ting the uterus, and plastic operations on the vagina and 
perineum, in almost every instance there was a rise in blood- 
pressure (Crile). Practically similar phenomena were seen 
in the different peritoneal and vaginal operations. Crile 
made observations also during nephrectomy, nephrotomy, 
nephrorrhaphy and suturing of the ureter. Nephrectomy 
was followed by a rapid fall in pressure, while in simple 
nephrotomy but slight effects were seen. 

In operations on the male genitalia, a fall in pressure 
was generally seen. 

The following chart from Cook and Briggs shows the 
effect on pressure of the Whitehead operation for hemor- 
rhoids. 

Fig. 42 



~ S ? 2 S 5 g 3 § 5 8 S „ § 2 5 


MM HG J | 


PULSE 


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Whitehead operation for hemorrhoid. (Cook and Briggs.) 



Operations on the Spinal Column. — Crile performed two 
laminectomies under cocain, and noted no change in pressure 
until the dura was reached, when a marked fall in pressure 
was seen. 



BLOOD-PRESSURE IN SURGICAL COMPLICATIONS 177 

Joachimsthal 1 has studied the effects of suspension on 
blood-pressure in orthopedic conditions and in cardiac lesion. 
Using the Dudgeon apparatus he made tracings in eight 
cases of vertebral deformity, scoliosis and spondylitis, and 
in cases of anemia and cardiac failure, and although his 
technique is not above suspicion he believes, that co-existing 
cardiac lesions, which have been heretofore regarded as a 
contra-indication are not affected by such treatment. 

Cowl and Joachimsthal 2 subsequently made experiments 
with frogs and rabbits, studying the effects on blood-pressure 
of applying weights to the suspended animal, and believe 
that extension of the spinal column does not affect the 
blood-pressure to any noticeable degree until the weight 
applied is about equal to the animal's body weight, when a 
slight rise in pressure will be observed. 

Operations on the Extremities. — Both Crile and Cook and 
Briggs have found a rise in pressure on stretching the 
sciatic nerve, which effect is well shown in the latter's 
chart. (See Fig. 38.) 

Amputation of limbs following railway accidents was fol- 
lowed by marked fall, but in an amputation of a shoulder- 
joint, in which the trunks of the tracheal plexus were cocain- 
ized, thereby "blocking the afferent impulses, no material 
changes in the blood-pressure was noted" (Crile). Bone 
operations produced small variations, the greatest changes 
being seen when the periosteum was attacked. 

Blood-pressure in Surgical Complications. — (A) Shock. — As 
old as this subject is, and as much discussed as it has been, 
physiologists and surgeons are by no means in accord as 
to its cause. At the present time there are two leaders in 
the shock research, Crile and Henderson, and as both have 
their partisans and both their opponents, both theories 
will be given. 

(a) Theory of Crile. 3 — Fall in the arterial blood-pressure 
is the essential phenomenon according to Crile, and without 
this fall there is no surgical shock. The cause of the hypo- 

1 Archiv fur Physiol. Abt., 1895, p. 200. 

2 Centralbl. fur Physiol., 1894-95, viii, p. 769. 

3 Harvey Lecture, 1908. 
12 



178 



BLOOD-PRESSURE IN SURGERY 



tension is traumatism of the nerve tissues and also physic 
stimuli. There is very little difference between death from 



























Fig. 


43 






























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290 
280 
270 
260 
250 
240 
230 
220 
210 
200 
190 
180 
170 
160 
150 
110 
130 
120 
110 
100 
90 
80 
70 
60 


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210 

230 
220 
210 
200 
190 
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Fatal postoperative shock. (Cook and Briggs.) 



hemorrhage and death from shock, both being due to failure 
of the circulation, producing certain degenerations of the 
central nervous system. It is assumed that the fall in 



BLOOD-PRESSURE IN SURGICAL COMPLICATIONS 179 

blood-pressure is mainly due to a functional impairment, a 
break down of the vasomotor centres, that the heart and 
bloodvessels themselves are only secondarily affected, prin- 
cipally by reason of the anemia of low blood-pressure; 
that the cause of the functional impairment or break- 
down of the vasomotor centres is due in part to the effect 
of excessive afferent stimuli, and in part to the progressive 
anemia of these centres, there occurring a species of vicious 
circle. These shock producing afferent stimuli are but little 
influenced by general anesthesia, but are totally blocked by 
cocainization of their conducting paths. 

In a later work 1 there is a resume of his views regarding 
the importance of operating on the principle of anoci 
association, which means the avoidance, as much as possible, 
of psychic and traumatic insults. Harmful or nocuous asso- 
ciations are called "noci associations," and if all nocuous 
associations are removed, this state is designated "anoci 
associations." 

Fig. 43, from Cook and Briggs, shows admirably the 
blood-pressure in fatal postoperative shock. 

(b) Theory of Henderson.' 2 — It is generally held that car- 
bon dioxid is the normal stimulant of respiration and that 
when this is diminished, respiration ceases. Henderson 
believes that when death follows intense physical suffering, 
not complicated by hemorrhage, there are two principal 
stages. At first the excessive breathing diminishes the 
carbon dioxid content of the blood. If at any time after 
this condition of acapnea (diminished carbon dioxid content 
of the blood) has been induced, the pain is greatly diminished 
and the respiratory centre is thus allowed to relapse into 
a standstill, fatal apnea vera may occur. If on the other 
hand, the pain is sufficiently continuous to keep the respira- 
tory centre continually excited, then apnea is prevented, 
and the condition of acapnea becomes more and more 
acute and general until the circulation fails, and the subject 
sinks into surgical shock. Both fatal apnea and the more 

1 Jour. Amer. Med. Assoc, 1912, lix, p. 114. 

2 Bull. Johns Hopkins Hospital, 1910, xxi, p. 235. 



180 BLOOD-PRESSURE IN SURGERY 

slowly developing failure of the circulation are due initially 
to acapnea induced by the excessive breathing occurring 
during torture. 

Henderson believes that respiratory failure precedes 
low blood-pressure, and in endeavoring to repeat Crile's 
work, has become more convinced of this view. In fact, 
he claims that the majority of Crile's dogs had behaved 
as had his, and that Crile's experience had been the same as 
his own, though differently interpreted. 

(B) Hemorrhage. — Hemorrhage can scarcely be classed as a 
surgical complication, for with the present surgical technique 
extensive bleeding rarely occurs. The effect of hemorrhage 
in surgery is precisely the same as that seen in typhoid 
(q. v.) and these effects cannot be more correctly gauged, 
both at the time of operation and afterward, than by fre- 
quent blood-pressure estimations. 

(C) Acute Dilatation of the Stomach. — There is no mention 
in the literature of blood-pressure in this common surgical 
complication. In a case of dilatation in pneumonia, the 
writer found the blood-pressure to be 95 mm. Hg. just before 
symptoms of dilatation began, having fallen from 114 the 
night before. The blood-pressure in postoperative dilatation 
would doubtless be low, as there is considerable shock 
associated with this condition. 



CHAPTER XII. 

BLOOD-PRESSURE IN CERTAIN CONDITIONS OF 
THE GASTRO-INTESTINAL TRACT. 

Intra-abdominal Pressure and Blood-pressure. — Experi- 
mentally, this question has been studied by Hamburger 1 
and Qurin. 2 Hamburger used physiological salt solution 
to raise the pressure in the peritoneal cavity and found that 
up to a certain point, the arterial pressure ran equally with 
the abdominal pressure, but when the latter was further 
increased, there was a fall in the former. Qurin employed 
air, but arrived at the same results as did Hamburger five 
years previously, and both are agreed that the phenomenon 
is best explained as follows: By increasing the abdominal 
pressure there is brought about increased resistance in the 
veins owing to the compression of the latter. The heart 
is called upon to do increased work and draws upon its 
reserve energy. When the pressure in the abdomen is still 
further increased, the heart becomes exhausted and the 
blood-pressure falls. Although neither authority applies 
his observations to man, it is apparent to the clinician just 
what pernicious effects a large accumulation of fluid must 
have on the general circulation, especially when such 
accumulations are secondary to disease of the heart. Early 
release of ascitic fluid is an imperative indication in those 
cases where the heart, owing to the valvular or muscular 
inefficiency, is alreadv laboring at a disadvantage. (See 
Chapter VIII, p. 146.) 

A recent contribution to the subject is that of Fundner 3 
who believes that the mechanical pressure on the diaphragm 

1 Archiv fur Phys., 1896, Physiolog. Abt., p. 332. 

2 Deutsch. Archiv fur klin. Med., 1901, lxxi, p. 79. 

3 Deutsch. med. Woch., 1913, p. 646. 



182 BLOOD-PRESSURE IN GASTRO-INTESTINAL TRACT 

has nothing to do with the increase of blood-pressure, but 
that the rise is due to reflex processes arising from the 
stomach. 

Relaxed Abdominal Walls. — It is generally supposed, 
although not all writers are in accord, that blood-pressure 
rises when the subject assumes an upright posture and falls 
when he lies down. Birtch and Inman 1 having observed, 
in patients suffering with enteroptosis and relaxed ab- 
dominal musculature, that the pressure fell 10 to 25 mm. 
Hg. on standing after lying, undertook extended studies 
with this as a text. The severity of the symptoms bore 
some relation to the amount of the systolic fall, being more 
marked with a low reading. On the days when the indi- 
viduals were feeling their best, the reading taken while 
standing remained close to the one obtained in the recum- 
bent posture. 

In cases of enteroptosis, as the table will show, there 
was a fall in systolic pressure from 10 to 25 mm. Hg. when the 
patient stood up, and the diastolic remained stationary 
or fell, decreasing the pulse pressure, as is seen in the healthy 
individual. They call attention to the fact that decrease 
in pulse pressure in persons with relaxed abdomens is caused 
by fall in systolic pressure, not by diastolic rise as is the 
case in health. 

As a contrast to these cases, the authors offer a second 
table showing the effect on blood-pressure of postural 
change in nephritis. In these individuals there was a 
preservation of systolic and diastolic pressures as is seen 
in athletic youths. The accompanying neuropathic symp- 
toms of visceroptosis are believed by Birtch and Inman to 
be due to the cerebral anemia and not to the malposition 
of the viscera," the cerebral anemia, in turn, being due to the 
muscular atony disturbing the splanchnic circulation. 

1 Jour. Amer. Med. Assoc, -1912, lviii, p. 265. 



RELAXED ABDOMINAL WALLS 183 



Type of Cases of Relaxation of the Abdominal Wall. 

















Pulse 


Pulse 


Subject. 


Time. 


Position. 


Maximum. 


Minimum. 


pressure. 


rate. 


1 


2.00 


R. 


118 






85 


33 


76 


1 


2.15 


S. 


92 






72 


20 


92 


2 


2.46 


R. 


124 






85 


39 


84 


2 


2.55 


S. 


104 






80 


24 


92 


3 


2.30 


R. 


130 






95 


35 


84 


3 


2.40 


S. 


110 






85 


25 


104 


4 


3.33 


R. 


110 






78 


32 


70 


4 


3.45 


S. 


100 






70 


30 


90 


5 


2.10 


R. 


120 






95 


25 


84 


5 


5.20 


S. 


110 






95 


15 


90 






Reclining (R.). 


Standing (S.). 










Average 


of Twenty- 


FIVE 


Cases. 







Fall of systolic 19.5 mm. 

Fall of diastolic 6.1mm. 

Fall of pulse-pressure 8.0 mm. 

Increase in pulse-rate 15.0 mm. 



Relaxed Musculature Complicated with Chronic Nephritis. 















Pulse 


Pulse 


Subject. 


Time. 


Position. 


Maximum. 


Minimum. 


pressure. 


rate. 


1 


2.15 


R. 


150 




95 


55 


72 


1 


2.25 


S. 


158 




110 


48 


76 


2 


11.05 


R. 


165 




110 


55 


68 


2 


11.15 


S. 


165 




110 


55 


74 


3 


11.30 


R. 


175 




90 


85 


64 


3 


11.45 


S. 


165 




90 


75 


66 


4 


12.14 


R. 


180 




95 


90 


78 


4 


12.25 


S. 


174 




110 


64 


90 






Reclinin 


g (R-). 


St< 


Hiding (S.). 







Average fall of systolic . . 2.00 mm. 

Average increase of diastolic 7.50 mm. 

Average fall of pulse pressure 10.75 mm. 

Average increase in pulse rate 6.00 mm. 



CHAP|TER XIII. 

BLOOD-PRESSURE IN DISEASES OF THE IN 
TERNAL SECRETORY GLANDS. 



I. DISEASES OF THE THYROID. 

Graves' Disease. — The only publications devoted speci- 
fically to the study of blood-pressure in Graves' disease 
are those of Maire, 1 Treves, 2 and Spiethoff, 3 the last named 
using the instruments of Riva-Rocci and von Reckling- 
hausen. The general opinion is that the blood-pressure is 
high, although this has been arrived at mostly by guess- 
work and not from actual experience. 

Spiethoff has made a thorough study of the pressure in 
20 patients, but found no constant relation between blood- 
pressure and severity of the illness. In patients with low 
blood-pressure (120 to 127 R.R.), the subjective symptoms 
were just as pronounced as in those with high pressure, 
(153 to 159 mm. Hg., R.R.). He concludes that the pressure 
is not uniform in the disease, and says that statements to 
the effect that blood-pressure is always high or always low, 
are incorrect. High and low pressures are met alike in 
severe cases of Graves' disease, while in the milder forms, 
normal pressures are the rule. This variability is believed 
to be, in the main, cardiac in origin, although vasomotor 
influences can not be excluded. 

Myxedema. — Gordon believes the blood-pressure is normal 
in this condition. 

1 These de Paris, 1883. 

2 Riv. iconogr. del policlin. gen. di Torino, 1897, i, p. 2. 

3 Centralbl. fur inn. Med., 1902, xxiii, p. 849. 



DISEASE OF THE PANCREAS 185 



H. DISEASES OF THE ADRENAL GLAND. 

(1) Acute Adrenal Insufficiency. — This comparatively rare 
condition, rare presumably because so infrequently recog- 
nized, has been rather cavalierly treated by recent writers, 
so far as blood-pressure observations are concerned. Bous- 
suet claims to have diagnosed acute insufficiency eight times 
by this symptom complex: asthenia, hypotension, nausea, 
vomiting, and diarrhea. The symptoms all subsided after 
hypodermics of adrenalin. Lavenson 1 has made a careful 
review of the subject in connection with the report of a 
case which he had observed, but unfortunately there were 
no blood-pressure estimations although the report of the 
examination seems to indicate vasomotor relaxation. 

A few years later, Cooke 2 reported a case, also without 
blood-pressure estimations. He made the very interesting 
and extremely valuable observation that solution of the 
diseased portions of the adrenals obtained at autopsy pro- 
duced no rise in blood-pressure in a dog, although the 
healthy portions of the same glands had pressor properties. 
That low blood-pressure must be a common feature, though 
not often reported, is apparent from these studies, and that 
the hypotension is in part due to functional deficiency of 
the adrenal seems also certain, and receives confirmation 
from Boussuet's findings. 

(2) Addison's Disease. — Hypotension is a constant feature 
in Addison's disease. 

Dock 3 reports four cases with pressures of 110 to 85, 
108 to 75, 85 to 65, and 82 to 60. The last two cases were 
seen only a few days before death. 

HI. DISEASE OF THE PANCREAS. 

Diabetes MeUitus. — One would expect to find cardio- 
vascular derangements in diabetes as in other toxic states. 

1 Archiv. Int. Med., 1908, ii, p. 62. 

2 Ibid., 1912 : ix, p. 108. 

3 Modern Medicine, Osier, vi, p. 368. 



186 BLOOD-PRESSURE IN SECRETORY GLANDS 

A study of total statistics shows that approximately 17 
per cent, of all diabetics have some cardiac degeneration, 
especially hypertrophy, but other changes are not infre- 
quently observed, i. e., fatty myocardial changes. The 
first studies from the stand-point of blood -pressure, are 
those of Potain, who found it to be very high, higher even 
than that seen in nephritis. This view is shared by Tiessier, 1 
while conflicting views are those of Vaquez, Hensen, and Ott, 
who all report cases showing hypotension. The writer has 
seen both high and low pressures, but low pressure more 
frequently. 

There is apparently no relation between the amount of 
sugar and degree of blood-pressure, except it be an inverse 
proportion. Acidosis seems to lower the systolic pressure, 
for in 10 cases, with an average age of thirty-three, the 
blood-pressure averaged 107 mm.; while in 15 cases with 
no sign of acid intoxication and an average age of fifty-three, 
the systolic pressure averaged 140 mm (Elliott 2 ). 

Complications are probably at the bottom of the hyper- 
tension, and only those cases which have nephritis or 
arteriosclerosis exhibit this phenomenon. A pure uncompli- 
cated diabetes, irrespective of the amount of glycemia, is 
not accompanied by increase of blood-pressure. 

Ehrmann 3 finds that some time before coma appears 
there is a marked decrease in blood-pressure, and he regards 
this as the cause of the diabetic collapse. 

IV. DISEASE OF THE PITUITARY. 

Acromegaly. — Gordon reports two cases with pressures 
of 110 and 90 respectively. Dr. Mark, in his extraordinary 
"Acromegaly" (a personal experience) unfortunately omits 
mentions of sphygmomanometric records. 

In a boy, recently under my care, who exhibited signs 
of disease of the posterior portion of the gland, there was 
hypotension. 

1 Gaz. des Hop., November 8, 1904. 

2 Jour. Amer. Med. Assoc, 1907, xlix, p. 27. 
:i Berlin, ldin. Woch., 1913, p. 13. 



CHAPTER XIV. 
BLOOD-PRESSURE IN OPHTHALMOLOGY. 

In cases of anemia, where there is usually low arterial 
blood-pressure, the veins of the retina are seen to pulsate, 
and this has been held to indicate a lowering of venous 
pressure. Cases of increased venous pressure are some- 
times associated with dilatation and tortuosity of the 
retinal veins. Increase of pressure is generally found in 
venous thrombosis of the vessels of the eye and brain, 
and in tumors pressing on the eye-ball, although the in- 
crease is but temporary. 

As far as increased arterial tension is concerned, the 
eye changes are not at all characteristic and cannot be 
differentiated from changes due to angiosclerosis. Indeed, 
the changes in the retina may precede and antedate any 
sphygmomanometric hypertension, and may occur inde- 
pendently of any general increased blood-pressure. The 
converse is also true, that hypertension, apart from arterio- 
sclerosis, can occur without any opthalmoscopic changes 
in the eye. 

de Schweinitz 1 calls attention to pathological alterations 
in the eye-ground when arteriosclerosis is the cause of the 
hypertension, dividing the changes into those which are 
suggestive and those which are pathognomonic. 

Of the suggestive signs, importance is laid on uneven 
calibre of the retinal vessels, and disturbance of the central 
light streak and an unusually light color of the breadth 
of the artery. The pathognomonic signs are changes in 
the size and breadth of the retinal arteries, giving a beaded 
appearance with a distinct loss of translucency. Peri- 
vasculitis, in the form of white stripes in the arteries, with 
alternate contractions and dilatations of the veins, and of 

1 Trans. Amer. Ophthal. Soc, 1906-08, xi, p. 87. 



188 BLOOD-PRESSURE IN OPHTHALMOLOGY 

most importance, indentation of the veins by the hardened 
arteries, are all valuable signs. As the condition progresses 
gray opacities around the disk or following the course of 
the vessels (edema) and hemorrhagic infiltrations or extra- 
vasations are seen. 

The eye changes are held to be of great importance in the 
diagnosis of arteriosclerotic hypertension, as these alterations 
are found in no other condition. (See Arteriosclerosis.) Just 
how early these signs appear is not definitely known, but it 
would seem that they are exhibited early enough to render 
an opthalmoscopic examination a very important aid in the 
diagnosis of arteriosclerosis. There is no mention of eye 
changes in cases of arteriosclerosis with normal or lowered 
blood-pressures. Were these changes to be noted, the eye 
examination would take precedence over any means at our 
disposal for diagnosing arteriosclerosis. Although it is of 
scientific interest and may be of clinical value to know 
definitely the condition of the blood-pressure in such states, 
it is far more important to know the eye changes in every 
case of hypertension. 

In estimating blood-pressure, one should never forget 
its lability, and should estimate values obtained only 
after the incidence of age, sex, work, mental state, etc., 
is taken into careful consideration. Since the blood-pressure 
instrument is now so firmly established as a necessary 
detail of the physician's armamentarium, it may not be 
too optimistic to hope that with the early recognition of 
hypertension and with treatment directed to its lowering, 
many cases of irrevocably impaired vision may be prevented. 

Optic nerve atrophy and retinal changes are commonly 
seen after severe hemorrhages, in which condition there 
is generally lowered blood-pressure. Cases of so-called 
progressive pernicious essential anemia with low pressure 
develop massive retinal hemorrhages, and this finding is 
not unusual in cases of secondary anemias of severe grades. 

Primary glaucoma is generally associated with hyper- 
tension. Lohlein 1 has devoted a special study to the cause 

1 Archiv fur Ophthal., 1912, lxxxiii, p. 547. 



BLOOD-PRESSURE IN OPHTHALMOLOGY 189 

of increased arterial pressure in glaucoma and discards as 
worthless the theory that adrenalin is the cause of the high 
blood-pressure. Certain of his cases had low pressure, 
105 mm. Hg. Unfortunately Lohlein does not state which 
instrument he used for his work. 

The eye change, seen in nephritis or in other conditions 
of increased intracranial pressure, are well known. Opthal- 
mologists seem to be united in the belief that retinal hemor- 
rhages are a direct result of increased arterial pressure, 
which does not in the least alter the apparently parodoxical 
statement that low pressure also seems to favor intra- 
ocular extravasations. 

From the stand-point of the ophthalmologist then, the 
estimation of blood-pressure is most important, as cases 
of retinal hemorrhages due to lowered pressure must be 
differently handled from those arising from hypertension. 
In the chapter devoted to treatment of hypertension, the 
great value of the sphygmomanometer in guiding the 
course of treatment will be discussed, but the point must 
be emphasized here, that there is in all cases of hyper- 
tension, a readjustment of physiological balance whereby 
the individual's standard exceeds 130 mm. Hg. — the normal 
systolic pressure (auscultatory). His normal limit may 
rise to 140 or 150 mm. Hg., and one should have continually 
before him the knowledge that, to reduce a pressure beyond 
the new limit which Nature has created for its own defense, 
is a malicious intrusion on her domain, and may be followed 
by dire consequences. No treatment directed at hyper- 
tension should ever be instituted without careful control 
of therapy by painstaking use of the sphygmomanometer. 



CHAPTER XV. 

EFFECT OF DRUGS AND OTHER THERAPEUTIC 
MEASURES ON BLOOD-PRESSURE. 

This chapter must in no way be considered a treatise 
on pharmacology and physical therapeutics. The endeavor 
has been in these pages, merely to present evidence con- 
cerning the action of certain therapeutic measures and 
drugs, which evidence, in part, at least, has led to the 
generally accepted opinions regarding their behavior in 
cases of hypertension and hypotension. 



I. HYPERTENSION. 

1. Drugs of the Nitrite Group. — (a) Nitroglycerin.— The 
effect of this drug was nil when given in tabloid form 
(Matthew), and the only preparation which yielded any 
results was the Solution trinitrini. 

The vasodilator effect followed within a minute after 
administration, and the reduction in pressure amounted to 
25 to 30 mm. Hg. The maximum effect is produced in 
five minutes, and is maintained for two minutes, after 
which time the pressure begins to rise again, reaching its 
original level in a half-hour. Repeated doses had no effect 
in reducing permanently the pressure. Matthew found a 
tolerance could be acquired, so that 4 c.c. (60 minims) a day 
were readily borne, but he calls attention to the possibility 
of doing harm by such doses. Headache and shortness of 
breath were early symptoms of toxicity both of which dis- 
appeared with the cessation of the nitrite. 

(b) Nitrites. — There is a vasodilator effect after the admin- 
istration of nitrites which is produced usually in five minutes 



HYPERTENSION 



191 



(Matthew), but the maximum effect (fall of pressure 32 mm.) 
is seen in fifteen minutes. The maximum fall is maintained 

Fig. 44 





cr H 

£h MINUTES 

mz Vz 1 2 3 \ 5 C> 7 S 10 12 14 If) 20 24 


M. M. HG. 

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0.13 c.c. (two minims) liquor trinitrini. (Matthew.) 

for from twenty to sixty minutes, the original pressure being 
again reached in one to two hours. Repeated doses of 0.13 













Fig. 


4") 


















2^ MINUTES 

Si 2 3 5 8 10 15 20 25 30 40 55 95 120 


M. M. HG. 

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255 

250 

245 

240 

235 

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0.13 (two grains) sodium nitrite. (Matthew.) 

(2 grains) of sodium nitrite three times a day, kept the blood- 
pressure down, not constantly at the lowest level of a single 



192 



EFFECT OF DRUGS ON BLOOD-PRESSURE 



dose, but still quite low, and after prolonged medication 
the pressure rose, within twenty-four hours, to its normal 
level, when the nitrite was discontinued. 

(c) Erythrol Tetranitrate. — The effect is evident in about five 
minutes, the fall of pressure being gradual and amounting 
to 35 mm. Hg. In about twenty-two minutes, the maximum 
effect is produced, which is maintained for about two hours, 
after which the rise toward the normal level sets in, the 
complete effect passing off in from five to six hours. There 
is no tolerance to this drug which is not so well borne as 
some of the other drugs. 















Fig. 


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2 £ MINUTES 

mil 2 3 4 5 6 8 10 12 16 20 50 160 360 4S0 


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0.06 (one grain) erythrol tetranitrate. (Matthew.) 



(d) Mannitol Nitrate. — In about fifteen minutes a fall of 
pressure begins, which reaches its maximum in two and a 
half to three hours (35 mm. Hg.). After three hours, the 
pressure begins to rise, reaching normal in about six hours. 

Matthew gives the following practical hints in prescrib- 
ing the foregoing vasodilator drugs: 

1. Liquor trinitrini. Where a single dose is prescribed, 
two minims is the one most likely to obtain the desired 
effect. 

2. Sodium and potassium nitrite. In suitable nitrite cases, 
0.13 (2 grains) produce a reduction of just over 30 mm. Hg. 
This action will last two hours and only after this is it 



HYPERTENSION 



193 



Fig. 47 





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mi 1 3 5 7 10 12 11 16 25 35 50 70 100 160 300 


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0.06 (one grain) mannitol nitrate. (Matthew.) 



Fig. 48 



OBSERVATIONS AT OBSERVATIONS AT 

FIVE-MINUTE INTERVALS TEN-MINUTE INTERVALS 

,_0 5 10 15 20 25 30 35 -10 15 50 55 00 70 80 90 100 110 11", 120130110150100170180 190200 


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175 
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Curve obtained by the use of sodium nitrite. The acceleration of the 
pulse rate during the fall in pressure is the rule; slowing of the pulse at 
that point was observed in a few cases. The systolic rise above the original 
level at the end of the curve is more common with this drug than with those 
causing a more gradual curve. No terminal diastolic rise above the original 
level was noted. Dastolic fall half the systolic. (Lawrence.) 
13 



Fig. 49 



205 
200 
195 
190 
185 
180 
175 
170 
165 
160 
155 
150 
115 


OBSERVATIONS AT OBSERVATIONS AT 
FIVE-MINUTE INTERVALS TEN-MINUTE INTERVALS 
) 5 10 15 20 25 30 35 40 45 50 55 GO 70 80 90 100 110 120 130110 150 1U0 170 180190 200 






















































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Curve characteristic of the action of erythrol. Less acceleration of pulse 
than with sodium nitrate. Diastolic fall very slight- — less than half 
systolic. (Lawrence.) 

Fig. 50 





|j OBSERVATIONS 
OBSERVATIONS AT OBSERVATIONS AT AT HALF-HOUR AND 
FIVE-MINUTE INTERVALS TEN-MINUTE INTERVALS HOUR INTERVALS 
) 10 15 20 25 30 35 40 45 50 55 GO 70 80 90 100 110120130U01501C01701801902202503103704304 


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Effect of mannitol. Acceleration of pulse slight. Diastolic fall slower 
than systolic and but slightly more than half as great. Diastolic rise slower 
than systolic, resulting in increased blood-pressure at end of curve. 
(Lawrence.) 



HYPERTENSION 



195 



necessary to repeat it. No benefit is obtained by increasing 
the dose, and a small dose will not give the desired effect. 

Fig. 51 





OBSERVATIONS AT II OBSERVATIONS AT finsl OBSERVATION AT END ! OF 
FIVE-MINUTE INTERVALS TEN-MINUTE INTERVALS eight and one HALF hoursJ| 
D 5 10 15 20 25 30 35 10 45 50 55 60 70 80 90 100 110120139 210270330390420 180 540 


260 
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210 
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230 
225 
220 
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200 
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180 
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Effect of vasotonin. A considerable and prolonged rise in both systolic 
and diastolic pressure. Pulse practically unaffected. The patient was 
suffering from arteriosclerosis. His kidneys were apparently only slightly 
affected. (Lawrence.) 



3. Erythrol tetranitrate. With this drug, a dose of 0.03 (§) 
to 0.06 (1) grain will produce a beneficial reduction, and the 
effect will last about six hours. Matthew recommends it to 
be used in all cases to start with. 

4. Mannitol nitrate. Doses of 0.06 (1) grain are useful, 



196 



EFFECT OF DRUGS ON BLOOD-PRESSURE 



and there is no individual susceptibility to the drug or any 
tendency to unpleasant effects from its use. 

In writing on the effect of pressure-lowering drugs and of 
therapeutic measures on systolic and diastolic pressure 
in man, Lawrence 1 makes some interesting contributions 

Fig. 52 




Effect of venesection. Action in this case less marked and less sustained 
than in others. Patient uremic and moribund. Pulse slowed. Diastolic 
fall two-thirds as great as systolic, therefore pulse pressure diminished less 
than by vasodilators. (Lawrence.) 

to our knowledge of such therapeutic agents. Observations 
were made with the Faught apparatus 12 cm. cuff, the 
systolic pressure being estimated by palpation and the 
diastolic by the auscultatory method. The drugs used 
were sodium nitrite, erythrol tetranitrate, mannitol hex a 
nitrate and vasotonin. 

The other therapeutic measures employed included 



1 Archiv. Int. Med., 1912, ix, p. 409. 



HYPERTENSION 



197 



venesection, hot-air baths, electric-light baths, and high fre- 
quency currents. Venesection reduced the pressure more 
persistently than any measure, in many cases the pressure 
did not regain its original level in twelve hours, and in 
another case not for thirty-six hours. Pressure was more 
frequently lowered after electric-light or hot-air baths than 
with the high frequency current. (Compare these charts 
with Matthews.) 

The practical conclusions are that sodium nitrite reduces 
diastolic pressure more rapidly than the more complex 
compounds, but that none of the nitrite group is efficient 
for maintaining pressure at a permanently lowered level, 
as a tolerance is soon acquired. If the dose be still further 
increased unpleasant symptoms result. 



Table I. — Average Blood-pressure Results from Administration of Nitro- 
glycerin, Sodium Nitrite and Erythrol Tetranitrate to Normal Persons. 







a a 


0-9 


on of 
min. 


Maximum 
extent of 


Drug. 




.3 O 




11 


action. 






Al 


S c3 


Q a 


Mm. Hg. 


Per cent. 


Amyl nitrite, 3 minims 




1 ! 3 


7 


15 


11 


Nitroglycerin, 1.5 mm., 


1 per 










cent, solution 




2 8 


30 


15 


11 


Sodium nitrite, 1 gr. . 




10 | 25 


60 


1-1 


13 


Erythrol tetranitrate, 


5 gr. 


15 


32 


120-240 


16 


14 



Table II. — Average Blood-pressure Results from Administration of 

Nitroglycerin, Sodium Nitrite and Erythrol Tetranitrate to 

Patients with Arteriosclerosis. 



Drug. 


Beginning 
action, min. 


Maximum 

affect, min. 


o 

II 
11 


Maximum 

extent of 

action. 




Mm. Hg. 


Per cent. 


Nitroglycerin -^ gr. . 
Sodium nitrite, 2 gr. . 
Erythrol tetranitrate, 2 gr. . 


2 
15 
30 


8 
45 
60 


35 
120 

180 


32 
53 
60 


17 
25 
30 



198 EFFECT OF DRUGS ON BLOOD-PRESSURE 

Venesection has a more lasting effect than any drug, 
the diastolic pressure remaining depressed much longer than 
the systolic pressure, thus lengthening the pulse pressure. 

The effects of hot-air baths, electric-light baths, high fre- 
quency current, and vasotonin are all uncertain, and the 
last named is unsafe and should never be used. 

The two tables on page 197 illustrate Wallace and Ringer's 
results with drugs of the nitrite group 1 given to normal and 
diseased individuals: 

2. Iodids. — When given to man, iodids have little effect 
in hypertension when the latter is due to nephritis as is so 
frequently the case. The good effects seen sometimes in 
arteriosclerosis may be due to the action on an underlying 
infection (syphilis) and not to any action on the arterio- 
sclerosis process itself. 

Intravenous injections seem to raise the blood-pressure 
in animals. 2 

Ghelfl 3 administered potassium iodid in increasing amounts 
to certain patients, and found at the beginning of the 
"cure" there was a rise of pressure of 30 to 40 mm., in some 
cases, and a fall in others. Continuance of the large doses 
of iodids ultimately leads to fall of blood-pressure with 
rapid pulse and vasodilatation. 

Matthew 4 believes that iodids have a typical vaso- 
dilator effect on the peripheral arterioles, acting in a way 
similar to nitrites, not with the latter's celerity of action, 
but with a much more prolonged effect. A single dose, 
however, is not followed by vasodilatation, but if repeated 
three or four times a day, and continued thus, an effect 
is manifest within thirty hours. Indication for the use of 
iodids is high blood-pressure without arteriosclerosis, but 
in advanced arteriosclerosis they have no hypotensive 
action. Organic iodids contain too little iodin to be 
efficient. Sajodin is to be used only when alimentary 
disorders contra-indicate the use of iodids. 

1 Jour. Amer. Med. Assoc, 1909, liii, p. 1629. 

2 Barbiera, Arch, fur d. ges. Phys., 1900, lxxix, p. 312. 

3 Abstr. in Munch, med. Woch., 1906, p. 2216. 

4 Edin. Med. Jour., 1911, i, p. 22P 



H 1 'PER TENSION 1 99 

3. Veratrum Viride. — Pesci 1 recommends the giving of 
20 to 30 drops of the fluidextract in all cases of hyper- 
tension in which the arteries still retain their elasticity. 
The best results with the drug are obtained in chronic 
nephritis, in which condition, the author says, it wards off 
uremia, and also tends to lessen the phenomena of the 
latter when once established. 

In vascular spasm of the abdominal vessels, as is found 
in chronic lead intoxications the drug is useful and also when 
such spasm is a part of general arteriosclerosis, the march 
of the latter process is said to be inhibited by the use of 
veratrum viride. 

The author cannot share the enthusiam which certain 
writers have for veratrum viride, and he has seen no good 
effects from its use. 

4. Effect of Carbon Dioxid Baths on Blood-pressure. — If 
one reads the earlier works on the effect of carbonic acid 
baths on blood-pressure, he will find the opinion universally 
expressed that carbon dioxid raises the blood-pressure 
and for that reason they should not be used in arterio- 
sclerosis. The Groedels 2 have shown that there is a slight 
rise in pressure on first getting into the bath, but it is no 
more of an elevation than one sees after many physiological 
acts. There follows very shortly a fall, which persists 
during the bath, but when the patient is removed from the 
bath, the pressure returns to normal. 

Laqueur 3 reports the results obtained in 100 patients, as 
far as blood-pressure, pulse pressure and pulse rate are con- 
cerned. He employed the apparatus of Fischer and Kiefer, 
using a mixture of carbon dioxid in cold water. Using a bath 
of 34° C. (93.2° F.) temperature, the systolic pressure was 
raised in 68.6 per cent, of the cases, although this increase 
was generally 2 to 5 mm. Hg., and in one case 23 mm. Hg. 
In 22.5 per cent, of the cases the pressure was lowered, 
and in the other cases it was unaffected. The pulse pressure 
was increased in 51 per cent, of the cases. The rise in 

1 Abstr. in Munch med. Woch., 1907, p. 281. 

2 Deutsch. med. Woch., 1906, p. 1371. 

3 Ztsch. fur exper. Path, und Therap., 1909, vi, p. 855. 



200 EFFECT OF DRUGS ON BLOOD-PRESSURE 

pressure is more marked in subjects with a functionally 
normal cardiovascular apparatus, more so than with baths 
of the same temperature, but containing no carbon dioxid. 
Oxygen baths have no such blood-pressure raising effect, 
due to the absence of cutaneous stimulation which arises 
from the carbon dioxid bath. Laqueur does not share 
the view of Senator, that the effect of carbon dioxid baths 
comes from the contrast of the cool water and the bubbles 
which give the sensation of warmth, but believes that there 
is some property in the carbon dioxid itself. 

In baths of 33° C. (91.4 F.) and below this temperature, the 
systolic pressure was found raised in 77 per cent, the pulse 
pressure was increased in 51 per cent, and the pulse rate 
diminished in 78.7 per cent. In cases of contracted kidneys 
and arteriosclerosis with hypertension, there is no decrease 
in blood-pressure or pulse pressure, although cases with 
" presclerose" often show a moderate fall. 

Newton 1 is much more enthusiastic than Laqueur re- 
garding the benefit of the Nauheim baths in cases of 
hypertension arising from nephritis, although he is un- 
informed as to their modus operandi. He leans to the belief 
that increased elimination through the skin is a not incon- 
siderable factor. 

A comprehensive study of the effect of Nauheim baths 
has been made by Swan 2 with results which differ materially 
from the above quoted, although there is no explanation 
offered for such contradictory opinions. 

There is, according to him, no constancy of action on the 
blood-pressure of carbonated brine baths, and there is no 
method of determining in advance whether a given treat- 
ment will be followed by an elevation or by a fall of pressure. 
The tendency of the bath is toward elevation, however, 
as the systolic pressure was raised more frequently than it 
was lowered. There are some cases of hypertension in 
which carbonated brine baths have produced a lowered 
systolic pressure, and there are others in which the ultimate 
pressure has been higher than it was at the beginning. 

1 Amer. Jour. Med. Sci., 1912, cxliii, p. 578. 

2 Arch. Int. Med., 1912, x, p. 73. 



HYPERTENSION 201 

5. Oxygen Baths. — In normal subjects there occurred 
practically no reduction in blood-pressure from the oxygen 
bath, but in most organic heart affections when com- 
pensation is fairly well established, the blood-pressure is 
almost unfailingly reduced. 1 Sadler believes that early 
arteriosclerosis (presclerosis) the effect of the baths is 
extremely beneficial, producing in one case a fall in blood- 
pressure of 35 mm., but in advanced arteriosclerosis the 
results are disappointing. In cases of functional hyper- 
tension, with no discoverable cause of the high blood- 
pressure, the baths have been found to have great value. 
The great contra-indication to their use is cardiac decom- 
pensation. 

Best results are obtained with a temperature of 34° C. 
(93.2° F.) to 35° C. (95° F.), but in certain nervous cases 
36° C. (97°) F. has been the temperature employed. The 
bath should not be given within an hour of bedtime. 

6. Carlsbad Cure. — Ritter 2 found a lowering of blood- 
pressure during Carlsbad cure. 

7. High Frequency Currents. — This form of current was 
demonstrated in 1891, by Nicola Tesla, being a current 
in which cycles of positive and negative waves exceed 
10,000 per second. 

As used in medicine, the frequency runs much higher 
then this low limit; the cycles ranging from 200,000 to 
2,000,000 per second, and with the tremendous voltage of 
from 10,000 to 500,000 volts. 

Both frequencies and voltages much in excess of these 
limits, may freely be passed through the system, but when 
given much higher than the limits mentioned, they gradu- 
ally lose their therapeutic properties on the human system. 3 

Van Rensselaer believes that the underlying causes of 
most cases of hypertension are metabolic, and that the high 
frequency current by improving the latter processes, reduces 
the high pressure. The current also checks the advance 
of the pathological processes seen in renal or cardiac dis- 
ease. 

1 Sadler, Amer. Jour. Physiol. Therap., 1910-11, i, p. 417. 

2 Deutsch. Arch, fur klin. Med., 1910, c, p. 11. 

3 Van Rensselaer, Albany Med. Jour., 1913, p. 77. 



202 EFFECT OF DRUGS ON BLOOD-PRESSURE 

Sayer 1 uses the current in doses of 0.028 to 3 units for 
six minutes, and believes a rise in pressure is apt to follow 
if stronger currents are employed. Individuals with low 
blood-pressure find the treatment very disagreeable. The 
mode of action of the currents is purely hypothetical. 
Bruce 2 publishes a report of a patient who died during 
treatment by high frequency current. 

8. Use of Diet in Hypertension. — The cardinal principles of 
a dietary directed toward the amelioration or cure of hyper- 
tension is detailed very clearly by Hecht. 3 The requisites 
of the diet are: 

1. "Spiceless" food. 

2. Lessening of the meat intake. 

3. Increase of vegetable diet with increase of mineral 

intake with the food. 

4. Lessening of fluid intake. 

5. Lessening of salt. 

6. Lessening or even cessation of alcohol. 

1. Such things as pepper, paprika, mustard, which are 
renal irritants, should be avoided. To make the food 
appetizing or rather to gain an appetite for the insipid 
tasting food, it is recommended to give 15 drops of the 
compound tincture of cinchona before each meal, and it is 
sometimes of value to insert a hunger day (greatly reduced 
amount of food) with rest in bed, as a stimulant to a jaded 
appetite. This spiceless food seems to have in the over-fed, 
corpulent type of individual, a very useful application, on 
account of its appetite decreasing properties, which tend 
to lessen the desire for alcohol and gourmandism. 

2. By lessening the meat intake, two results are obtained — 
a cutting down of the excessive protein intake and a great 
reduction of the so-called "extractives." The majority 
of individuals eat too much, and more people die of over- 
eating than of overdrinking. Voit has placed the lowest 
protein requirement at 1.5 grams per kilogram body weight, 
but Chittenden's experiments have shown the obvious 

i Brit. Med. Jour., 1910, ii, p. 1052. 

2 Medical Electrol. and Radiol., 1905, vi, p. 231. 

3 Ztsch. fur klin. Med., 1912, lxxvi, p. 87. 



HYPERTENSION 203 

fallacy of this, as he has been able to keep hard-working 
men in nitrogen balance on food containing but 0.7 to 0.9 
grams per kilogram body weight. As substitutes for meat, 
milk and cheese may be used. There should be no distinc- 
tion made between light or dark meat. The latter is, to 
be sure, freer of extractives, but these can be removed 
by boiling. 

3. Vegetable diet. In cases of uncomplicated non- 
albuminous hypertension (presclerose) the blood-pressure 
can be brought to normal in a few days on purely vegetable 
food. In nephritis, such results are never seen, although a 
lowering of pressure is seldom missed. In cases of neuras- 
thenia, with depression, a vegetable diet is to be especially 
recommended. When there is malnutrition associated 
with the high blood-pressure, a carbohydrate rich food is 
especially useful. Vegetables such as spinach, peas, cabbage, 
cauliflower, Brusselssprouts, beans, carrots, beets, potatoes 
and cereals are recommended. With the meat there should 
be two vegetables, one boiled and the other rice or potatoes 
in various forms. Four evenings a week it may be advisable 
to have a pure vegetable day or a cereal day. Salad (no 
vinegar) and radishes (the latter only when there is no 
gastro-intestinal disease or nephritis) may be freely used. 
Fresh or stewed fruits are especially valuable. 

When obesity is combined with hypertension, fats and 
carbohydrates must be restricted, especially cereals, bread 
and potatoes. The latter may be eaten twice a week, and 
bread to the extent of 20 to 40 grams, given as toast or 
zwiebach. Rice (30 grams raw or 80 grams boiled) once a 
day. Fatty food is best avoided, but a small amount of 
butter 10 to 15 grams in the morning) may be given. Tea, 
coffee, and stewed fruit are best taken without sugar. Asso- 
ciated with properly regulated passive or active massage, 
both hypertension and obesity can be very much benefited. 

4. Fluid intake. If fruit, compote, vegetables and salads 
are eaten, water with meals may be dispensed with, since 
the non-stimulating diet does not produce excessive thirst. 
Caffein-free coffee and very weak tea, both not too hot, may 
be induced in very small amounts. 



204 EFFECT OF DRUGS ON BLOOD-PRESSURE 

5. Salt intake. It is questionable if sodium chlorid has, 
of itself, any blood-pressure raising properties, but since 
it causes thirst, necessitating the use of much water which 
does seem to raise pressure, a salt-poor diet is advisable. 

6. Alcohol. Although we have learned that alcohol, 
per se, does not raise blood-pressure it has an injurious 
effect on the bloodvessels and in this way tends to raise 
pressure. 

Food should be well chewed, the intervals between meals 
should not be too long as they lead to weakness and to 
intense thirst and hunger. 



II. HYPOTENSION. 

1. Digitalis. — Hypodermic injections of digitalin act more 
promptly and more energetically than strychnin, but its 
effects are not so permanent. A combination of the two 
drugs is of service when strychnin alone fails to raise the 
pressure. 

Tincture of digitalis in cases of hypotension and hyper- 
tension produced no blood-pressure rise (Tinct. digitalis ulxv 
every four hours) (Burnet), while others claim that it some- 
times raises, sometimes lowers, and sometimes does not 
change the blood-pressure, that is to say, the maximal 
pressure. It does, however, always lower the diastolic 
pressure thereby increasing the pulse pressure. 

Price 1 discredits analogies being drawn between animal 
experimentation and observations in man, concerning 
the action of digitalis. In the former, very large doses 
can be studied, which is impossible in man. He studied 
(Riva-Rocci) the effect of 5j of the tincture a day, and 
found in twenty-one cases, that there was a rise in pressure 
in only one case, in fact, in several cases there was a fall, 
and he believes digitalis does not raise the human pressure 
by constricting the peripheral vessels. He says if this 
conclusion is correct, then there is no contra-indication to 

1 Brit. Med. Jour. 1912, ii, p. 689. 



HYPOTENSION 



205 



its use in excessive hypertension and in cases of excessive 
disease of the arterial walls. 

In some cases, dilatation of the heart may be due to 
increased arterial tension and digitalis in these cases, by 
improving the blood-supply of the brain, lessens the activity 
of the vasoconstrictor centre and a lower arterial tension 
often follows. Digitalis itself is without effect in raising 
blood-pressure. 

Fig. 53 



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Fatal relapse in typhoid fever. Profound toxemia, showing effect of 
digitalin. (Cook and Briggs.) 

2. Strychnin. — When strychnin is given in doses of 0.001 to 
0.006 gram there is a rise in blood-pressure which is not so 
prompt as that induced by alcohol, but is more permanent 
(one to four hours). The drug when continued for eight or 
twelve doses seems to be without pressor effect, but if omitted 
for one or two doses, the action will again be seen. " On the 
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the maintenance of a satisfactory blood-pressure level, free 



206 



EFFECT OF DRUGS ON BLOOD-PRESSURE 



from intervals of depression, being most easily accomplished 
by its use in appropriate doses." (Cook and Briggs, see 
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(Cook and Briggs.) 

In some cases strychnin seems to be useless. These are 
moribund individuals with a circulatory apparatus rapidly 
failing, and in such a condition further forcing is hopelessly 
contra-indicated. A second class of cases includes those 
individuals with healthy tone of heart and vessels. 

3. Alcohol. — The only indication for the use of alcohol, is 
toxemia. As a cardiac stimulant or as a vasomotor con- 
strictor it is absolutely inert and any rise in blood-pressure 
which follows its use is wholly transient and results from a 
reflex action through irritation of the afferent nerves in 
the mucous membrane or in the skin, when administered 
hypodermically. It has no more vasomotor action than 



HYPOTENSION 



207 



has other irritants like tincture of capsicum. (Cook and 
Briggs.) (See Influence of Alcohol on Blood-pressure, 
Chapter V.J 

4. Camphor. — Although extolled by continental writers as a 
valuable stimulant, its worth seems to have been held 
sub judice by American clinicians. Cook and Briggs point 
out that as a pressor drug it is absolutely inert in cases of 

































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long-continued depression, as in typhoid fever. In cases of 
cardiac decompensation with hypotension, the writer is 
in accord with their observations that it has distinct merit 
in doses of 10 to 20 minims of a 10 per cent, solution. The 
indication for its use is well covered by digit alin, especially 
when the latter is used in combination with strychnin. 

5. Cocain. — Cocain has a distinct pressor effect and must 
be classed as a true stimulant. Used with strychnin and 
digitalin in cases of postoperative or posthemorrhagic 



208 



EFFECT OF DRUGS ON BLOOD-PRESSURE 



hypotension it possesses decided value. (Cook and Briggs.) 
The blood-pressure has been seen to rise 20 mm. Hg., after 
0.015 or 0.03 grain, and they recommend its use with saline 
injections, giving to the latter a "positive stimulant value 
which they do not otherwise possess." (Fig. 56.) 



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6. Strophanthus.— In some cases it produces rise in pressure. 

7. Squill. — Uncertain in blood-pressure raising action. 

8. Caffein. — Raises pressure. 

9. Pituitrin. — The watery extract of the infundibular por- 
tion of the beef hypophysis seems to have, if authors are 
to be believed, wonderful properties. It is said to have a 
marked influence on metabolism, and to inhibit the growth 
of bone, although these are less important than its action 
on the smooth muscle of the body. It excites intestinal 
peristalsis, causes contraction of the uterus through the 
sympathetic uterine nerves, and brings about contraction 
of the bladder with consequent emptying. 

As far as the circulatory apparatus is concerned, it causes 
vasoconstriction and with it, increased blood-pressure. As 
a cardiac stimulant it acts by slowing and strengthening 
the heart-beat. The only field of smooth muscle on which 



HYPOTENSION 209 

it exerts no vasoconstrictor effect, in fact, the only vessels 
which it causes to dilate, are those of the kidney, with 
ensuing diuresis. Intramuscular injections of pituitrin 
are followed by rise of pressure to 30 mm. Hg\; this rise 
persisting for thirteen hours. 

Klotz 1 found that in animals pituitrin caused a rise in 
pressure, only when the same was below normal, but it 
was without effect on normal pressure. Observations on 
women with uterine hemorrhages resulting in lowered 
blood-pressure showed the effect of the injection to be 
most striking. 

The dose is 0.2 gram fresh glandular substance put up 
in an ampoule of 1 c.c. (Burroughs, Wellcome & Co.), 
or in | c.c. ampoule with 0.05 gram fresh extract. There 
seems to be no danger of overdosing, as animals tolerate 
sixty times this dose. A second injection, before the effects 
of the first have worn off, has no effect on the pressure. 
Contra-indications, to its use are nephritis, "goitre heart," 
arteriosclerosis, and diseased heart muscle. It has been used 
in shock, and Klotz recommends its administration in pneu- 
monia, diphtheria (?), and diseased heart muscle (?). In 
man, its administration is without danger, but in animals 
it causes hepatic and renal degeneration, hypertrophy of 
the adrenals and heart. It is doubtful if it can produce 
arteriosclerosis, and it is without organic effect on the 
heart. I have had no success with pituitrin in cases of 
persistent hypotension. 

10. Adrenalin. — The effect of adrenalin is so fugacious that 
its administration hardly seems feasible. The appended chart 
(Fig. 57) from Janeway shows how temporary are the effects, 
and also how alarming may be the depression which follows. 

1 1 . Salt Solution. — In but one of a hundred cases (other than 
hemorrhage) have injections of salt solutions produced a rise 
of blood-presure (Cook and Briggs). When a rise was seen, 
it was due to purely local and peripheral nervous causes. 
When the needle is introduced, especially if there is much 
pain, there is often a momentary rise (10 mm. Hg.), and 

1 Munch, med. Woch., 1911, p. 1119. 

14 



210 



EFFECT OF DRUGS ON BLOOD-PRESSURE 



Fig. 57 



March 24 


ONE MINUTE INTERVALS 




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Extreme rise in blood-pressure produced by the intravenous injection 
of adrenalin. (Janeway's sphygm., 12 cm.) (1) Adrenalin chloride (1 in 
1000), TTlxx, injected into the median basalic vein. With the rise, which 
followed instantly, there was throbbing in head, excitement, substernal 
pain, and nausea; (2) no pulse palpable; heart sounds very faint; patient 
delirious, pale. Strychnin sulphate, gr. -g^, and atropin sulphate, gr. ?%-$, 
given hypodermically; (3) caffein sodium salicylate, gr. ii, given hypoder- 
mically. In spite of the alarming secondary depression (an unusual result) 
there was no bad after-effects. 



HYPOTENSION 211 

as the solution flows into the tissues, and as the local tension 
increases, the blood-pressure rises to a considerable degree 
(20 to 40 mm. Hg.). With this rise the pulse feels stronger 
and fuller, as if the bloodvessels were filling. The rise in 
tension is at first rapid, then slower, then begins to fall 
slowly, the blood-pressure reaching normal in from fifteen 
minutes to half an hour. 

If the infusion be intermittent, instead of continuous, 
the blood-pressure will be found to rise or fall as the fluid 
is introduced or interrupted. When giving a continuous 
infusion of 1000 c.c, lasting an hour, the blood-pressure 
will return to normal long before the infusion is completed. 

The writers believe that any effects from salt solution 
are due to peripheral reflex action on the vasomotor centre 
and can be duplicated by any form of intermittent or con- 
tinued nerve irritation. 



CHAPTER XVI. 

TREATMENT OF HYPERTENSION AND 
HYPOTENSION. 

Treatment of Hyperpiesis. — In the treatment of hyper- 
piesis an important fact must not be lost sight of, namely, 
that high blood-pressure is often a necessary accompani- 
ment of altered function and structure, and were it not for 
this raised blood-pressure, life could not be carried on with 
these functional or organic changes. One finds himself 
between Scylla and Charybdis, between the danger which 
threatens if pressure remains high and the danger which is 
certainly imminent if pressure is too suddenly reduced, or 
reduced too low. For there is a real danger in prolonged 
hypertension, that of arterial degeneration, hemorrhages, 
and cardiac failure, and there is the undoubted danger of 
sudden collapse or of cardiac insufficiency if the pressure 
is kept too low. It will be recalled that cardiac strength and 
peripheral resistance are necessary for the maintenance of 
blood-pressure at a certain level, and it must not be for- 
gotten that the increase of blood-pressure may be the expres- 
sion of a rearranged vasomotor mechanism, which is the 
only one, under the circumstances, capable of keeping the 
heart functionating. In individuals with normal blood- 
pressures, to reduce the pressure below a certain physiological 
limit is a serious event, as we have seen in previous chapters. 
What the physiological limit for each individual is, no one 
can say; it is a variable but never a negligible quantity. 
Increased blood-pressure has of necessity a raised physio- 
logical limit below which blood-pressure cannot be reduced 
with impunity any more than can blood-pressure in health 
be reduced below the normal physiological limit. 

Some regard hypertension in certain conditions of neph- 



HABITS 213 

ritis as indispensable for the maintenance of function. 
Krehl believes that the high blood-pressure is but compensa- 
tory in order to bring about elimination of toxic products. 
If so, then limiting the formation of such substances will 
automatically reduce blood-pressure, as is often observed 
when a pure milk diet, or salt-poor diet, is employed, but 
to lower blood-pressure by therapeutic measures, when the 
intake is furnishing the dangerous metabolites, is to rob 
Nature of the only means of defense which she now possesses. 

When measures are given to combat high blood-pressure 
their effects should always be controlled by the sphygmo- 
manometer. 

The first indication of any rational treatment of hyper- 
tension (hyperpiesis) is to ascertain, if possible, the exciting- 
cause or the chief contributing causes, and it is more by the 
correcting of these than by any drugs that good is accom- 
plished. If business, professional, or domestic cares are at 
the bottom of the trouble, these should, if possible, be 
removed, or made to occupy a less prominent place in the 
patient's life. 

^Ye have learned the effect of emotion on blood-pressure, 
and Cannon and de la Paz have demonstrated clearly that 
the epinephrin content of the blood is raised over the normal 
in an angry animal. Can there be an application of this 
truth to man? The tragic death of John Hunter in St. 
George's Hospital, following an attack of choler, is too 
well known to need more than mention, but its lesson is 
not so well comprehended. 

If finances permit, absence from home in a warm, balmy, 
equable climate should be urged, with congenial surround- 
ings, away from the superheated atmosphere of the modern 
life. The patient should have rest from mental worries 
as well as from physical exertion. The latter does not 
forbid moderate exercise, golf and walking, but aims at 
the lessening of the terrific pace at which we are living. 

Diet. — The reader is referred to the full extract of Hecht's 
article given in Chapter XV. 

Habits. — -These should be inquired into most thoroughly. 
Habits of work and habits of play should be understood 



214 HYPERTENSION AND HYPOTENSION 

as well as habits of tobacco and alcohol. One can play too 
hard and one can work too hard, and both should be 
regulated. Tennis, for instance, is a game for youth, and a 
man past fifty-five should play it very moderately if at all, 
and then preferably doubles. Tobacco should be tactfully 
interdicted, and gradual discontinuance is better than 
sudden abolition. If the patient has been an excessive 
smoker, to discontinue the habit abruptly is apt to have 
more serious consequences than the hypertension, which 
we are aiming to correct. Nevertheless, tobacco should 
eventually be absolutely forbidden. The opinions vary as 
regarding alcohol. Of itself, alcohol has little action on 
blood-pressure, but secondarily it has a pernicious effect 
on the bloodvessels, leading to arterial degeneration (arterio- 
sclerosis) and for this reason temperance is advisable. 
Total abstinence is rarely required, and the advice to 
abstain is seldom adhered to, for both of which reasons, 
alcohol may be permitted in great moderation, preferable 
in the form of whisky. One should not worship at the shrines 
of Venus, Bacchus, Vulcan and Minerva with too much 
assiduity. 

Elimination. — Elimination should be increased. To stimu- 
late elimination by the kidneys, water is no doubt of 
great value, but in nephritic hypertension, the advisa- 
bility of free water drinking is doubtful. It seems as un- 
reasonable to stimulate a diseased organ as to make a 
broken limb perform its natural function; both demand 
rest. In cases of hypertensive cardiovascular disease, 
water is contra-indicated, as liquids tend to raise blood- 
pressure. If water is to be taken it should be between 
meals, and the taking of fluid with the meals should be 
greatly restricted. 

Sweat baths, either steam or dry heat, are very useful, 
but the excessive thirst Avhich sometimes follows, should 
not be yielded to, and no water should be drunk. Moderate 
massage following the bath is recommended. 

The bowels should be kept loose. It is far better to 
have free purgation than a condition of constipation. 
Saline purges taken in hot water before breakfast and a 



DRUGS 215 

blue mass pill (0.3 gram) once or twice a week will secure 
the desired effect. 

In robust individuals, venesection is often followed by 
benefit, but the author has never seen any permanent 
good result. Cushing's advice regarding venesection in 
cases of cerebral hemorrhage should be remembered. 

High Frequency Currents. — High frequency currents seem 
to have met with approval in experienced hands. 

Drugs. — As far as drugs are concerned, they are of less 
value than diet, free purgation and hygiene. The fact that 
hypertension often causes cardiac decompensation and 
that this cardiac decompensation increases the hyper- 
tension, is sufficient indication for the employment of 
digitalis. High blood-pressure is not a contra-indication 
to its use, as digitalis, given by mouth, is inert as far as 
any specific action on pressure is concerned. Indeed digi- 
talis administered to these cases with failing heart may be 
a means of lowering the hypertension by relieving the 
cardiac decompensation. Iodids, as stated in previous 
pages, possess little value unless syphilis is an underlying 
factor of the high pressure. Sodium nitrite, nitroglycerin 
and erythrol tetranitrate may be used, but the effects, 
in the best cases, are transitory (see Chapter XV) . If the 
hypertension is associated with paroxysms of pain, pearls 
of amyl nitrite (0.12 to 0.3) may be carried on the person 
and used as occasion demands. I have seen good results 
follow this prescription. 

Potassium nitrate 0.65 

Potassium bicarbonate 0.65 

Sodium nitrite 0.03-0.13 

This is to be taken on rising in 100 c.c. of Apenta water. 
In cases of extreme hypertension, one may add to the powder 
0.015 to 0.13 gram erythrol tetranitrite. 

The treatment as outlined above has necessarily been 
given in general terms and applies to the cases of hyper- 
piesis without cardiac decompensation. When the heart 
begins to falter, and signs of the beginning lagging of the 
right heart make their appearance (see Chapter V), rest 



216 HYPERTENSION AND HYPOTENSION 

in bed is imperative. The diet which I am fond of pre- 
scribing consists of milk, given four times a day, in portions 
of 200 c.c. No other fluid is allowed. Digitalis is here 
indicated, and I have seen good results from digipuratum, 
given in doses of 0.09 gram three times a day. Morphin, 
when the patient is restless or nervous, is most valuable. 
Sweat baths frequently repeated, are not contra-indicated, 
and good results have been seen in those cases which have 
at first appeared to be too weak to stand them. Active pur- 
gation should not be neglected. Venesection is once more 
being recognized as a useful measure, and in those cases of 
decompensating hypertensive cardiovascular disease, the 
removal of 200 c.c. of blood is often most useful. 

Prognosis of Hyperpiesis. — In the first phase of hyper- 
piesis, especially if one is fortunate enough in seeing patients 
early, the heart and bloodvessels have undergone relatively 
slight damage, if any, and the prognosis is good if a rational 
mode of living is followed. When arterial changes are 
seen, it may be said that the younger the individual, the 
worse the prognosis, especially when treatment has not 
proven efficacious. Just how great the arterial changes are, 
we can surmise only from palpation of a very few vessels, 
and this, of course, affords but little idea of the degree 
of sclerosis of hidden vessels, notably those supplying the 
viscera. A careful eye examination is helpful in forming 
an opinion, quoad vitam, damaged retinal vessels making the 
outlook much more gloomy than it would be with intact 
arteries. 

Signs of decompensation always render the prognosis 
guarded (see Chapter V). Apart from the dyspnea of rest, 
the earliest sign is tachycardia, and the slower the pulse 
rate, the better the prognosis. A pulse rate above 90 is 
to be regarded seriously. The pulsus alternans renders 
the prognosis grave. In cases of hyperpiesis, when blood- 
pressure begins to fall and the symptoms begin to become 
prominent, a guarded prognosis should be made. The 
appearance of some albumin in a large amount of urine 
of low specific gravity is not of much consequence, but a 
sudden increase with scanty urine is a danger signal. 



TREATMENT OF HYPOTENSION 217 

Treatment of Hypotension. — The treatment of hypo- 
tension depends essentially on the cause of the hypotension. 
With the exception of epidemic cerebrospinal meningitis, 
acute infections are hypotensive, but this hypotension, as a 
rule, calls for no treatment. When the hypotension is 
causing grave symptoms, rapid weak pulse, embarrassed 
respiration, and signs of impending collapse, treatment is, 
of course, indicated. In pneumonia, the falling of blood- 
pressure below the pulse-rate (see Pneumonia) is a fair 
index when to begin treatment. Treatment of these emer- 
gencies — shock, acute infections, collapse from any cause — 
is now well understood, but the continued use of the sphyg- 
momanometer makes the indications for treatment more 
certain. 

There is much evidence to show that fatigue and waste 
products accumulate in a muscle which is doing work or 
which is tired from much activity. Gruber has lately 
shown that the height of contraction of a fatigued muscle 
may be increased 100 to 125 per cent, when the blood- 
pressure is below 90 to 100 mm. Hg., but only 5 to 25 per 
cent., when the pressure is above 100 mm. Hg., or in other 
words, when the blood-pressure is low a small rise has 
many times the effect that it has when the pressure is 
high. This, Gruber believes, is due to the increase of 
efficiency in the circulation following the rise in pressure, 
thereby carrying away more rapidly the fatigue products 
which have accumulated in the muscle. 

He also demonstrates that lowered arterial pressure 
is followed by a decrease in the height of muscular contrac- 
tion. In the experimental animal a fall in pressure from 
120 to 100 mm. Hg., was accompanied by no appreciable 
decrease in the height of contraction; when to 90 mm. Hg., 
the decrease was 2.4 per cent.; when to 80 mm. Hg., a 
decrease of 7, and when to 70 mm. Hg., a decrease of 17.3 
per cent. 

There occurs in practice, with greater frequency than is 
suspected, a class of cases, which runs a persistent low 
blood-pressure, pressures below 110 mm. Hg. To these 



218 HYPERTENSION AND HYPOTENSION 

the author has recently called attention, 1 pointing out a 
common symptom-complex headache, vertigo, mental and 
physical tire. There is still another group of cases of hypo- 
tension, which is doubtless due to malnutrition, no demon- 
strable organic disease having been found (tuberculosis, 
carcinoma, anemia, Addison's disease). 

These long-standing cases of hypotension associated with 
the above-mentioned clinical state show great improvement 
when the blood-pressure is raised. It is sometimes a diffi- 
cult task to cause any increase in tension, but it is grati- 
fying to note that even a small rise of pressure is followed 
by a subjective improvement, the latter out of proportion 
to the increase in pressure. In the treatment of these cases 
general hygienic measures are more important than drugs. 

Such patients should be instructed to retire at a reasonably 
early hour, and to rise at a certain fixed time. 

Immediately on rising they are to perform a series of 
exercises, consisting of free movements, somewhat after 
the following plan. 

Daily Exercises. — 1. Stand erect with the arms extended, 
and the fingers in contact above the head. Stoop forward 
and try to touch the floor with the finger tips, moving slowly, 
and return again to the original position. 

2. Lie at full length on the floor or bed upon the 
back, with the hands under the hips, and bring each leg 
alternately and slowly to a position at right angles to the 
body. 

3. Perform the same motions with both legs con- 
jointly. Lying at full length upon the back, the hands 
elapsed behind the head, bring the elbows in, bend the body 
forward till the face touches the knees, returning again 
slowly to the original position. 

4. Standing position, extend the arms sidewise, the elbows 
straight, until the hands meet above the head. Stretch the 
arms as much as possible in doing this. Inhale deeply as 
the arms go up, and exhale slowly as they come down. 

1 Amer. Jour. Med. Sci., 1914, cxlvii, p. 503. 



COLD SPONGE BATH 219 

5. With the hands on the hips, the thumbs behind, 
without moving the feet turn the trunk as far as possible 
to the right, then to the left. As the body turns rub the 
fingers deeply into the abdomen. 

6. Raise the arms laterally, the palms upward, until the 
level of the shoulders is reached, bring them forward until 
the fingers touch; then reverse the movement, extending 
the arms backward as far as possible, at the same time 
rising upon the toes. 

7. Breathing. — Hands at hips, head bent backward, inhale 
through nose; head erect, exhale through nose and mouth, 
five to ten times. 

Time. — On arising. 

Temperature of Room. — As cold as temperature outside. 

Windows open. 

In order that the exercises should have the desired effect, 
they must be performed regularly, every morning, at least 
ten minutes being devoted to the task. They should at 
first be performed slowly, with intermissions of a few seconds 
for rest, and deep breathing. As the muscles become 
accustomed to the work, they may be increased in rapidity 
and duration, but never to the extent of producing exhaus- 
tion or prolonged breathlessness. 

Following these exercises, or some similar to these, a 
shower bath should be taken, first hot, and then as cold as 
can be well born. If there are no such appointments, a 
good substitute may be obtained in the following: 

Cold Sponge Bath. — To be taken: 

1. After morning exercise. 

2. On rising. 

Stand erect in the tub in which a little hot water remains, 
and sponge the entire body quickly with cold fresh or salt 
water; or pour a pitcher of cold water over the back and 
spine, or use a douche or spray. This should be immediately 
followed by a brisk rub w T ith a coarse towel, continued long 
enough to produce redness of the skin. Following this, 
rest in the recumbent position, well covered up, for five 
or ten minutes before dressing. Bath room should be 
warm. 



220 HYPERTENSION AND HYPOTENSION 

Definite rules should be given for the number of hours' 
work to be done in each day, and a certain fixed amount of 
relaxation should be insisted upon. Golf, riding, tennis, 
walks in the country, are all useful in bringing about a 
temporary dropping of business, professional and domestic 
trials. Exercise should be regulated according to the age 
and physical condition of the subject. A youth with hypo- 
tension can be ordered to do much more violent exercise 
than can a man of middle life, and for the former, for instance, 
tennis may be recommended, whereas the older man's 
strength is sufficiently taxed by the more moderate game of 
golf. 

Tincture of nux vomica in ascending doses will be found 
to be advantageous, beginning with 15 drops three times 
a day and increasing 3 drops a day. The limit to the increase 
is seen in the first sign of the physiological action of the 
drug, and when this is recognized, the single dose is dropped 
5 drops and maintained there for a period of two to five 
days. After this the number of drops is decreased 15 drops 
a day to the original dose, maintained there for a week, 
and then discontinued. 

Given in this way unusually large doses may be given. 
Patients not uncommonly have taken 50 drops three times 
a day, and 75 drops were taken by one of my patients. 

Excessive indulgence in tobacco, alcohol, tea, and coffee 
should be corrected. These and other detrimental habits, 
too individual to enumerate, should receive due attention, 
and one should strive by a sensible conduct of life to bring 
the cardiovascular function to a normal state of activity. 

It is very difficult to raise blood-pressure in such cases, 
but it is encouraging to note that but small rises are 
associated with considerable improvement. 



INDEX. 



Abdomen, effect of pressure within, 

on blood-pressure, 146, 181 
Abdominal walls, relaxation of, 182 
A. C. E. mixture, 173 
Acromegaly, 186 
Addison's disease, 185 
Adrenal insufficiency, acute, 185 
Adrenalin, 185 

administration of, 209 

as a cause of hypertension, 119 
Age, influence of, 62 
Air, compressed, 74 

rarefied, 74 
Alcohol, 69 

effect of, on blood-pressure, 207 
Alcoholism, 143 
Altitude, 75 

effect of, in tuberculosis, 141 
Amyloid kidney, 114 
Anaphylactic shock, 137 
Anemia, 104 

Anesthesia, spinal, 173. See Anes- 
thetics. 
Anesthetics, A. C. E. mixture, 173 

chloroform, 172 

cocain, 173 

ether, 170 

nitrous oxid, 172 

nitrous oxid and oxygen, 173 
Aneurysm, 103 

difference in pressure in arms, 
104 
Angina pectoris, 94 
Anginoid pains, 94 
Aortic insufficiency, 89 

blood-pressure in leg and 

arm in, 89 
increase of pulse pressure 
in, 89 



Aortic insufficiency, low diastolic 
pressure in, 89 
significance of the fourth 
phase in, 89 
Aortic stenosis, 90 
Arms, difference in pressure in, in 
aneurism, 104 
between legs and, in aortic 
insufficiency, 89 
influence of size of, 62 
Arteriosclerosis, 101 

hypertension in, 101 
hypotension in, 87 
Articular rheumatism, acute, 139 
Ascites, 146 

effect of tapping in. 146, 147, 
181 
Asthma, 146 
Auricular fibrillation, 94 
clinical, 96 
experimental, 94 
Auscultatory method, phases heard 
in, 58 
significance of the fourth 
phase in aortic insuffi- 
ciency, 89 
significance of phases 

heard in, 60 
technique of, 57 



B 



Barometric pressure, 74 
Baths, effect of carbon dioxid, 
199 

influence of, 76 

oxygen, 201 
Blood-flow, in arteries, 17 

in capillaries, 19 

in veins, 19 



222 



INDEX 



Blood-pressure, estimation of, hints 
for, 60 

technique of, 56 
factors determining mainten- 
ance of, 17, 20, 22 
history of, 36 
instruments, Chauveau, 40 

Erlanger, 53 

Fick, 43 

Gaertner, 50 

Guettet, 37 

Hales, 36 

Hiirthle, 43 

Ludwig, 38 

Magendie, 38 

Marey, 44 

Milne-Murray, 41 

Nicholson, 56 

Philadelphien, 46 

Poiseuille, 37 

Riva-Rocci, 48 

Stanton, 53 

Tycos, 53 

v. Basch, 47 
physiology of, 17 
value of, 24 
Bloodvessels, blood-flow in, 17, 19 
constriction of, 24 
dilatation of, 24 
pressure in various, 21 
resistance of, 20, 24 
size of, 24 
Bronchitis, 146 



Caffein, effect of, on blood- 
pressure, 208 
Camphor, effect of, on blood- 
pressure, 207 
Capillary pressure, 33 

estimation of, 34 
in disease, 35 
in various vessels, 35 
Carbon dioxid baths, effect of, on 

blood-pressure, 199 
Cardiac function, tests for, 97 
Herz, 99 
Katzenstein, 98 
Mendelsohn - Graup- 

ner, 98 
objections to, 100 
Schott, 100 



Cardiac neurosis, 92 
Cardiovascular system, pressure in 

various parts of, 21 
Carlsbad cure, effect of, on blood- 
pressure, 201 
Cerebral compression, 151, 153 
Cheyne-Stokes respiration, 158 
Children, 62 

effect of illness in, 63 

of school examinations on, 
63 
Chloroform, 172 
Cholera, 139 
Circular insanity, 161 
Clinical significance of phases, 60 
Cocain as a local anesthetic, 173 
effect of, on blood pressure, 
207 
Compressed air, 74 
Compression of artery as test of 
cardiac function, 99 
influence of, on blood- 
pressure, 66 
Convalescence, 77 
Cuff, width of, 49, 57 



Decapsulation of kidney, effect of, 

on blood-pressure, 114 
Decompensation, blood-pressure in, 

82, 91 
Diabetes mellitus, 185 
Diastolic pressure, 57, 59 

low, in aortic insufficiency, 
89 
Diet, in hypertension, 202, 213 
Digitalis, effect of, on blood-pres- 
sure, 204 
Diphtheria, 136 

prognostic value of blood- 
pressure in, 137 
Druckpuls, 144 

Drugs, blood-pressure and, 190 
Ductus Arteriosus Botalli, 90 
Dyspnea, 145 



E 



Eclampsia, 167 

differentiation between, and 
epilepsy, 168 
and uremia, 168 



INDEX 



223 



Edebohls' operation, effect of, on 

blood-pressure, 114 
Edema, acute pulmonary, 144 
Effusions, abdominal, 146 
effect of tapping of, 146 
pleural, 146 
Emphysema, 146 

Epidemic cerebrospinal meningitis, 
134 
effect of lumbar punc- 
ture in, 136 
Epilepsy, 162 

diagnosis between, and 
eclampsia, 168 
Erythrol tetranitrate, effect of, on 

blood-pressure, 192 
Ether, 170 

Exercise, effect of, in cardiac 
disease, 92 
influence of, 70 



Functional tests of cardiac effi- 
ciency, 97. See 
Cardiac func- 
tion, 
objections to, 
100 



G astro-intestinal diseases, 181 

General paresis, 161 

Glaucoma, 188 

Gout, 143 

Graves' disease, 184 



H 



Heart, diseases of, 89 

influence of exercise in diseases 
of, 92 
High frequency current, effect of, 
on blood pressure, 201 
in hypertension, 215 
Hyperpiesis, 79 
Hypertension, 79 

in acute nephritis, 101 
adrenalin as a cause of, 119 
in arteriosclerosis, 101 



Hypertension in asthma, 146 

blood-sugar as a cause of, 119, 
186 

cause of death in, 83 
in nephritis, 115 

in cerebral compression, 151, 
153 

in chronic interstitial neph- 
ritis, 111 

in chronic parenchymatous 
nephritis, 110 

drugs and other therapeutic 
measures in, 190 

in eclampsia, 167 

effect of continued, 83 

of high frequency currents 
in, 215 

elimination in treatment of, 
214 

in glaucoma, 188 

in gout, 143 

habits, regulation of, in, 213 

increase of erythrocytes as 
cause of, 105 

in lead poisoning, 143 

in meningitis, 135 

pathogenesis of, 82 

postpartum, 169 

prognosis of, 216 

significance of, in insurance, 
147 

symptoms of, 81 

treatment of, 212 

in typhoid fever, 126 

in uremia, 113 
Hypertensive cardiovascular dis- 
ease, 79 
Hypotension, 68, 84 

in acromegaly, 185 

in Addison's disease, 185 

in amyloid kidney, 114 

in anaphylactic shock, 137 

in arteriosclerosis, 87 

causes of, 85 

in cholera, 139 

in chronic interstitial nephritis, 
111 
parenchymatous neph- 
ritis, 111 

cold baths in treatment of, 219 

definition of, 85 

drugs and therapeutic meas- 
ures in, 204, 212, 215 

exercises in, 218 



224 



INDEX 



Hypotension in influenza, 139 
in lead poisoning, 143 
in orthostatic albuminuria, 123 
in paratyphoid fever, 140 
in shock, 177 
in tuberculosis, 140 
strychnin in, 220 
treatment of, 217 
in typhoid fever, 124 
in uremia, 113 



Influenza, 139 

occurring in course of neph- 
ritis, 114 
Inhibitory nerves, 25 
Insanity, 159 

circular, 161 
Insurance, 147 
Intra-abdominal pressure, effect of, 

on blood-pressure, 146, 181 
Iodides, effect of, on blood-pres- 
sure, 198 



Kidney, decapsulation of, 114 



Lactation, 168 
Laparotomy, 175 
Lead poisoning, 142 
Lumbar puncture, effect of, 157 
in meningitis, 136 

M 

Malaria, 139 

Mania, 160 

Mannitol nitrate, effect of, on 

blood-pressure, 192 
Meals, influence of, 67 
Melancholia, 159 
Menstruation, 77 
Mental diseases, 159 
Mercuric chlorid poisoning, 143 
Mitral insufficiency, 90 
Mitral stenosis, 90 
Mountain sickness, 76 
Midler's experiment, 75 



Myasthenia gravis, 162 
Myocarditis, acute, 91 

chronic, 91 
Myxedema, 184 



N 



Nephrectomy, 123 
Nephritis, 107 
acute, 108 
chronic interstitial, 111 

parenchymatous, 110 
classification of, 107 
intercurrent infections in, 114 
prognostic value of blood- 
pressure in, 112 
Nerves, atrophy of optic, 188 
inhibitory, 25 
vagus, stimulation of, 22 
vasoconstrictor, 25 
vasodilator, 25 
vasomotor, 25 
Nervous disorders, 151 
Neurasthenia, 162 
Nitrites, effect of, on blood-pres- 
sure, 190 
Nitroglycerin, effect of, on blood- 
pressure, 190 
Nitrous oxid, 112 

and oxygen, 173 
Normal blood-pressure, 62, 79 



Obstetrics, 165 
Old age, 64 

Ophthalmology, blood-pressure and, 
187 
optic nerve atrophy and, 188 
Orthostatic albuminuria, 123 
Oxygen baths, effect of, on blood- 
pressure, 201 



Pain, 71, 73 

anginoid, 94 
Paroxysmal tachycardia, 97 
Periodic variations of blood-pres- 
sure, 64 



INDEX 



225 



Phases of auscultatory method, 58 
clinical significance 

of, 60 
in polycythemia, 106 
significance of fourth, 
in aortic insuffi- 
ciency, 89 
Pituitrin, effect of, on blood- 
pressure, 208 
Pneumonia, 129 

blood-pressure pulse-rate ratio, 
131 
Pneumothorax, 144 
Poiseuille's law, 20 
Polycythemia, 105 
hypertonica, 105 
phases in, 106 
Postpartum hypertension, 169 
Posture, influence of, 66 
Pregnancy, 165 

effect of, on blood-pressure, of 

stages of, 166 
variations of blood-pressure 
in, 165 
Pressure pulse, 144 
Psychic states, influence of, 71 
Pulmonary edema, acute, 144 
Pulse pressure, 57 

increase of, in aortic insuf- 
ficiency, 89 



Q 



Quotidian variations of blood- 
pressure, 65 



R 



Salt solution, effect of/ on blood- 
pressure, 209 
Scarlet fever, 138 

complications of, 138 
prognostic value of blood- 
pressure in, 138 
School examinations, effect of, in 

children, 63 
Shock, anaphylactic, 137 
surgical, 177 
theories of, 177 
Sleep, influence of, 66 
Sphygmobolometry, 61 
Spinal anesthesia, 173 
Squill, effect of, on blood-pressure, 

208 
Stimulation of vagus, 22 
Strophanthus, effect of, on blood- 
pressure, 208 
Strychnin, effect of, on blood pres- 
sure, 206 
use of, in hypotension, 220 
Surgical complications, 177 

acute dilatation of stom- 
ach, 180 
hemorrhage, 180 
shock, 177 
operations, 170, 174 
abdominal, 175 
genito-urinary, 175 
importance of blood-pres- 
sure records in, 170 
on extremities, 177 
on head and neck, 174 
on spinal column, 176 
on thorax, 174 
Systolic pressure, 57, 59 



Rarefied air, 74 

Raynaud's disease, 146 

Relaxation of abdominal walls, 
influence on blood-pressure of, 
182 

Renal conditions, 107. See Neph- 
ritis. 

Renin, 117 

Resistance of blood-vessels, 20, 
24 

Respiratory diseases, 145 

Rheumatism, acute articular, 
139 

15 



Tabes dorsalis, 163 

Tapping of effusion, effect of, 146, 
147, 181 

Temperament, influence of, 64 

Temperature, 74 

Temporary variations of blood- 
pressure, 65 

Tobacco, influence of, 69 

Traube-Hering waves, 26 

Tuberculosis, 140 
altitude in, 141 



226 



INDEX 



Tuberculosis, fever in, 141 
hemorrhages in, 141 
prognostic value of blood- 
pressure in, 141, 142 
Typhoid fever, effect of, on heart 
and vessels, 127 
hemorrhage in, 125 
perforation in, 126 



Valsalva's experiment, 74, 75 

Variations of blood-pressure 

cardiac neurosis, 93 

in pregnancy, 165 

periodic, 64 

quotidian, 65 

temporary, 65 



Vasoconstrictor nerves, 25 
Vasodilator nerves, 25 
Vasomotor centres, 26 

factors influencing, 26 
peripheral, 28 
spinal, 28 
Vasomotor mechanism, 25 
nerves, 25 

anatomy of, 29 
Venous pressure, 30 

'as a means of estimating 
cardiac function, 33, 
100 
effect of drugs on, 33 
of exercise on, 33 
estimation of, 30 
in disease, 33 
Veratrum viride, effect of, on 

blood-pressure, 199 
Volume of blood, 24 






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